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THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 

ISAAC HAYS, M.D., 

FEI-LOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OP THE 
AMERICAN MEDICAL ASSOCIATION ; OF THE AMERICAN PHILOSOPHICAL SOCIETY ; OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; ASSOCIATE FELLOW 
OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES, 
&C. &C. &C. 



NEW SEEIES. 
YOL. XXXYIL 




PHILADELPHIA: 
BLANCHARD AND LEA. 
1859. 



69463 



Entered according to tlie Act of Congress, in the year 1859, by 
BLANCHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 




PHILADELPHIA ! 
COLLINS, PRINTEB. 



TO READERS AND CORRESPONDENTS. 



The following works have been received : — 

On Epilepsy and Epileptiform Seizures, their Causes, Pathology, and Treat- 
ment. By Edward Henry SievekinOx, M. D., F. R. 0. P., &c. &c. London. 
John Churchill. 1858. (From the Author.) 

On Ve sic 0- Vaginal Fistula, and its successful Treatment. Illustrated by 
eleven cases. Read before the British Medical Association, at Edinburgh, July 
31, 1858. By I. Baker Brown, F. F. C. S., &c. &c. &c. London, 1858. (From 
the Author.) 

The Microscope in its Application to Practical Medicine. By Lionel Beale, 
M. B., F. R. S., &c. Second edition, with 270 wood-cuts and a coloured plate. 
London, John Churchill, 1858. (From the Author.) 

Syllabus of the Course of Lectures on Medical Logic, delivered in Mareschal 
College and University, Aberdeen. By Francis Ogston, M. D., Prof. Med. 
Logic and Med. Jurisp. Edinburgh, 1858. (From the Author.) 

Etudes sur la Monorchidie et la cryptorchidie chez I'Homme. Par M. Ernest 
GrODARD, Interne des Hopitaux de Paris, &c. Extrait des Memoires de la So- 
ci6te de Biologic. Paris, 1857. (From the Author.) 

On Amputation by a Long and a Short Rectangular Flap. By Thomas P. 
Teale, F. L. S., &c., Surgeon to the Leeds General Infirmary. Illustrated by 
engravings on wood, by Mr. Bagg. London, John Churchill, 1858. (From the 
Author.) 

A Treatise on the Human Skeleton (including the joints). By George Mur- 
ray Humphrey, Esq., M. B. Cantab. F. R. C. S., Surgeon to Addenbrooke's Hos- 
pital, Lecturer on Surgery and Anatomy in the Cambridge University Medical 
School. Cambridge. 1858. (From the Author.) 

Selections from the Records of the Government of Bengal. Published by 
authority. No. xxviii. Reports on the Asylums for European and Native In- 
sane Patients at Bhowanipore and Dallunda for 1856 and 1857. Calcutta, 185B. 

The Pathology and Treatment of Stricture of the Urethra, and Urinary Fis- 
tula. By Henry Thompson, F. R. C. S., M. B. Lond., &c. &c. Second edition, 
much enlarged and revised. London, 1858. (From the Author.) 

Sur une Fonction peu connue du Pancreas la Digestion des Aliments Azotes, 
Experiences paralelles sur la Digestion Gastrique et Intestinale; Inductions 
Cliniques. Par Lucien Corvisart. Paris, 1857-'58. (From the Author.) 

Observations on Diphtheritis. By Willoughby F. Wade, B. A., M. B., &c. 
&c. London, 1858. (From the Author.) 

A System of Human Anatomy, General and Special. By Erasmus Wilson, 
F. R. S., &c. A new and improved American from an enlarged London edition. 
Edited by Wm. H. Gobrecht, M. D., Prof. Anat. in Philada. Coll. Med. With 
397 illustrations on wood. Philadelphia : Blanchard & Lea, 1858. (From the 
Publishers.) 

■ A Practical Treatise on the Diseases of Children. By D. Francis Condie, 
M. D., F. C. P. P., &c. &c. Fifth edition revised and enlarged. Philadelphia: 
Blanchard & Lea, 1858. (From the Publishers.) 

A Treatise on the Venereal Disease. By John Hunter, F. R. S. With 
copious additions, by Dr. Philip Ricord, Surgeon to the H6pital du Midi, 
Paris, &c. Translated and edited, with notes, by Freeman J. Bumstead, M. D., 
Lecturer on Venereal at the Coll. Phys. and Surg, N. Y. Second edition, re- 
vised, containing a resume of Ricord's recent Lectures on Chancre, Philadel- 
phia: Blanchard & Lea, 1859. (From the Publishers.) 

The Science and Art of Surgery. Being a Treatise on Surgical Injuries, 
Diseases, and Operations. By John Erichsen, Prof. Surg, and Clin. Surg, in 
University College, and Surgeon to University College Hospital. An improved 
American edition, from the second enlarged and carefully revised London edi- 
tion. Illustrated by 417 engravings on wood. Philadelphia: Blanchard & Lea, 
1859, (From the Publishers.) 



4 



TO READERS AND CORRESPONDENTS. 



Brief Expositions of Eational Medicine ; to whicli is prefixed the Paradise of 
Doctors, a Fable. By Jacob Bigelow, M. D., late President of Massacliusetts 
Med. Soc, &c. Boston: Phillips, Sampson, & Co., 1858. (From the Author.) 

The Modern Practice of Midwifery. A Course of Lectures on Obstetrics, de- 
livered at St. Mary's Hospital, London. By Wm. Tyler Smith, M. R. C. P., 
with an introductory Lecture on the History of the Art of Midwifery, and 
copious practical annotations, by Aug. K. Gtardner, M. D., &c. &c. Illustrated 
by 212 engravings. New York : R. M. Be Witt, 1858. (From the Editor.) 

Selections from Favourite Prescriptions of Living American Practitioners. 
By Horace GtReen, M. D., &c. &c. &c. New York : Wiley & Halstead, 1858. 

Illustrations of Typhus Fever in Great Britain, the result of personal observa- 
tions made in the summer of 1853, with some remarks as to its origin, habits, 
symptoms, and pathology; to which is appended a brief account of the re- 
appearance of Typhus in Boston in the winter of 1857-'58. By J. B. Upham, 
M. D., &c. Boston, 1858. 

A Treatise on Fractures. By J. F. Malgaigne, Chirurgien de I'Hopital St. 
Louis, &c. &c. With 106 illustrations. Translated from the French, with notes 
and additions, by J ohn H. Packard, M. D. Philadelphia : J. B. Lippincott & 
Co., 1859. (From the Translator.) 

A Treatise on Diseases of the Air Passages : comprising an inquiry into their 
history, causes, and treatment, of those affections of the throat called Bronchitis, 
Chronic Laryngitis, Clergyman's Sore Throat, &c. &c. By Horace Green, 
M. D., &c. &c. Fourth edition, revised and enlarged, with an appendix. New 
York : Wiley & Halsted, 1858. 

An Essay on the Climate and Fevers of the Southwestern, Southern Atlantic, 
and Gulf States. By Jas. C. Harris, M. D., of Wetumpka, Ala. New Orleans, 
1858. (From the Author.) 

Diphtheritis : a concise historical and critical essay on the late epidemic 
Pseudo-membranous Sore throat of California (1856- 57) , with a few remarks 
illustrating the diagnosis, pathology, and treatment of the disease. By Y. J. 
FouRGEAUD, M. D. Sacramenta, 1858. 

An Inaugural Dissertation on Strychnia : presented to the Medical Faculty of 
McGill Medical College, May 1, 1858. By Alex. P. Reid. Montreal, 1858. 

Induced Abortion, on account of extreme Narrowness of the Pelvis. Prize 
Essay of the Medical Faculty of Tubingen. Abridged and published by Ferd. 
Rallenmann, M. D. , &c. Philadelphia, 1858. 

Report on the Chemical Analysis of the White Sulphur Water of the Arte- 
sian Well of Lafayette, Ind. With remarks on the nature of Artesian Wells. 
By Chas. M. Wetherill, Ph. D., M. D. Lafayette, Ind., 1858. 

Description of a New Midwifery Forceps, having a sliding pivot to prevent 
compression of the foetal head (with cases) . By Geo. T. Elliott, Jr., M. D. 
(From the Author.) 

The Treatment of the Paralysis of Motion. By Charles F. Taylor, M. D., 
&c. (From the Author.) 

An Inaugural Address, delivered before the New York Academy of Medicine, 
February 3, 1858. By J. P. Batchelder, M. D., President elect. New York, 
1858. (From the Author.) 

Communications to the Massachusetts Medical Society. By Ephriam Cutter, 
M. D. Boston, 1858. (From the Author.) 

An Essay on Inflammation. By J. H. Watters, M. D. St. Louis, 1858. 
(From the Author.) 

On Medical Colleges. An Introductory Lecture to the Course of 1858-'59 of 
the Medical Department of the University of Nashville. By J. Berrien Linds- 
LEY, Chancellor of the University. Nashville, 1858. 

Quarterly Summary of the Transactions of the College of Physicians of Phila- 
delphia. From March 3 to August 4, 1858, inclusive. 

Transactions of the Third Session of the Medical Society of the State of Ca- 
lifornia, convened at San Francisco, February, 1858. Sacramento, 1858. 

Annual Report to the Legislature of South Carolina relating to the Registra- 
tion of Births, Marriages, and Deaths, for the year ending December 31, 1857. 
Columbia, 1858. (From R. W. Gibbes, Jr., M. D., Registrar.) 



TO READERS AND CORRESPONDENTS. 



5 



Fifth Eeport to the General Assembly of Khode Island, relating to tlie Eegis- 
try and Keturns of Births, Marriages, and Deaths, in the State, for the year 
ending December 31, 1857. Prepared under the direction of John E. Bartlett, 
Sec. of State. Providence, 1858. 

Constitution, By-Laws, and Code of Ethics of the Iowa State Medical Society, 
together with the Transactions of the Eighth and Ninth Annual Meetings, held 
in Iowa City and Mount Pleasant, 1857-1858, (Davenport, 1858.) 

Twenty-Second Annual Eeport of the Officers of the Vermont Asylum for the 
Insane, Aug., 1858. (Brattleboro', 1858.) 

The following Journals have been received in exchange : — 

Annales Medico-Psychologiques. Par MM. Baillarger, Cerise, et Moreau. 
July, October, 1858. 

Le Moniteur des Hopitaux. Eedacteur en chef: M. H. De Castelnau. Sep- 
tember, October, November, 1858. 

Journal de la Physiologie de I'Homme et des Animaux. Public sous la direc- 
tion du Docteur E. Brown-Sequard. July, 1858. 

Journal de Medecine de Bordeaux. Eedacteur en chef: M. Costes. August, 
September, October, 1858. 

Ophthalmic Hospital Eeports, and Journal of the Eoyal London Ophthalmic 
Hospital. Edited by J. F. Streatfeild. July, 1858. 

Edinburgh Medical Journal. September, October, November, 1858. 

British Medical Journal, Edited by Andrew Winter, M. D. September, 
October, November, 1858. 

Dublin Hospital Gazette, September, October, November, 1858, 

Medical Times and Gazette. September, October, November, 1858. 

The British and Foreign Medic o-Chirurgical Eeview. October, 1858. 

Guy's Hospital Eeports. Edited by Samuel Wilks, M. D., and Alfred Po- 
land. October, 1858. 

The Sanatory Eeview and Journal of Public Health. Edited by B. W. Ei- 
CHARDSON, M. D. October, 1858. 

The Journal of Psychological Medicine and Mental Pathology. Edited by 
Forbes Winslow, M. D. October, 1858. 

Edinburgh Veterinary Eeview. October, 1858. 

The Glasgow Medical Journal. July, October, 1858. 

The Indian Annals of Medical Science. July, 1858. 

The Dublin Quarterly Journal of Medical Science. November, 1858. 

The Medical Chronicle. Edited by Mr. "VYright, M. D., D. C, MacCallum, 
M. D, Oct,, Nov,, Dec, 1858, 

The Boston Medical and Surgical Journal, Edited by W. W. Morland, M, D., 
and Francis Minot, M, D, October, Nov,, Dec, 1858. 

The Chicago Medical Journal. Edited by N. S. Davis, M. D., and W. H. 
Byford, M. D. Aug., Sept., Oct., Nov., 1858. 

Buffalo Medical Journal, Edited by Austin Flint, Jr., M. D. October, No- 
vember, December, 1858, 

The Cincinnati Lancet and Observer, Edited by George Mendenhall, M. D., 
J. A. Murphey, M. D., and E. B. Stevens, M. D. October, November, Decem- 
ber, 1858. 

The Medical and Surgical Eeporter. Edited by S. W. Butler, M. D., and W. 
B. Atkinson, M. D. October, Nov., Dec, 1858. 

American Druggists' Circular and Chemical Gazette. October, Nov., Dec, 
1858. 

American Medical Gazette. Edited by D, M. Eeese, M. D. October, Nov., 
Dec, 1858. 

The Maine Medical and Surgical Eeporter. Conducted by Dr. W. E. Eichard- 
soN and E. W, Cummins. October, Dec, 1858. 

The Peninsular and Independent Medical J ournal. Edited by A. B. Palmer, 
M. D., MosEs GuNN, M. D., and F. Stearns. October, November, Dec, 1858. 

Atlanta Medical and Surgical Journal. Edited by J. P. Logan, M. D., and 
W. F. Westmorland, M. D, October, November, Dec, 1858, 

Nashville Journal of Medicine and Surgery. Edited by W. K. Bowling, M, D., 



6 



TO READERS AND CORRESPONDENTS. 



R. C. FosTEE, M. D., and George S. Blackie, M. D. October, November, Dec, 
1858. 

Oglethorpe Medical and Surgical Journal. Edited by H. L. Byrd, M. D. and 
Holmes Steele, M. D. June, August, October, 1858. 

The Virginia Medical Journal. Edited by James B. McCaw, M. D. and J. 
Otis, M. D. October, November, December, 1858. 

Southern Medical and Surgical Journal. Edited by H. F. Campbell, M. D. 
and Robert Campbell, M. D. October, November, Dec, 1858. 

The American J ournal of Insanity. Edited by the Medical Officers of the 
New York State Lunatic Asylum. October, 1858. 

The Medical Journal of North Carolina. Edited by Edward Warren, M. D. 
Aug., October, 1858. 

The New Orleans Medical and Surgical Journal. Edited by Bennett Dowler, 
M. D. November, 1858. 

The American Journal of Science and Arts. Conducted by Professors B. 
SiLLiMAN, B. SiLLiMAN, Jr., A. Gray, L. Agassiz, and Dr. W. Gibbs. Novem- 
ber, 1858. 

New York Journal of Medicine. Edited by Stephen Smith, M. D. Novem- 
ber, 1858. 

Charleston Medical J ournal. Edited by J. Dickson Bruns, M. D. November, 
1858. 

Proceedings of the Academy of Natural Sciences of Philadelphia. October, 
November, 1858. 

The Nashville Monthly Record of Medical and Physical Science. Edited by 
D. F. Wright, M. D., and R. 0. Curry, M. D. October, November, December, 
1858. 

New Orleans Medical News and Hospital Gazette. Edited by D. W. Brick- 
ell, M. D., and E. I). Fenner, M. D. October, November, December, 1858. 

The New Hampshire Journal of Medicine. Edited by G. H. Hubbard, M. D, 
October, November, 1858. 

The Pacific Medical and Surgical Journal. Edited by John B. Trask, M. D., 
and David Worster, M. D. August, September, October, November, 1858. 

The American Journal of Dental Science. Edited by Chapin A. Harris, 
D. D. S., and A. S. Piggot, M. D. October, 1858. 

The North American Medico-Chirurgical Review. Edited by S. D. Gross, 
M. D., and T. G. Richardson, M. D. November, 1858. 

St. Louis Medical and Surgical Journal. Edited by M. L. Linton, M. D., and 
W. M. McPheeters, M. D. November, 1858. 

American Journal of Pharmacy. Published by Authority of the Philadelphia 
College of Pharmacy. Edited by William Procter, Jr. November, 1858. 

The Ohio Medical and Surgical Journal. Edited by John Dawson, M. D., 
and J. W. Hamilton, M. D. November, 1858. 

The Savannah Journal of Medicine. Edited by J. S. Sullivan, M. D., Juriah 
Harriss, and R. D. Arnold, M. D. November, 1858. 



Communications intended for publication, and Books for Review, should be sent, 
free of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the 
Medical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed 
as above, and (carriage paid) under cover, to John Miller, Henrietta Street, Covent 
Grarden, London; or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will 
reach us safely and without delay. We particularly request the attention of our 
foreign correspondents to the above, as we are often subjected to unnecessary ex- 
pense for postage and carriage. 

Private communications to the Editor, may be addressed to his residence, 1525 
Locust Street. 

All remittances op money, and letters on the business of the Journal, should be 
addressed exclusively to the publishers, Messrs. Blanchard & Lea. 

The advertisement-sheet belongs to the business department of the Journal, 
and all communications for it should be made to the publishers. 

To secure insertion, all advertisements should be received by the 20th of the 
previous month. 



CONTENTS 



AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. LXXIII. NEW SERIES. 

JANUARY, 1859. 



ORIGINAL COMMUNICATIONS. 

MEMOIRS AND CASES. 

ART. PAGE 

I. On the Mimite Structure of tlie Hepatic Lobules, particularly with refer- 
ence to the Relationship between the Capillary Bloodvessels, the Hepatic 
Cells, and the Canals which carry ofiP the Secretion of the latter. By H. 

D. Schmidt, M. D., of Philadelphia. (Illustrated with 33 Figures.) . 13 

II. Remarks on Sunstroke. By James J. Levick, M. D., of Philadelphia. . 40 

III. Cases of Exhaustion from Heat treated in the New York Hospital by 
Stimulants and Ice to the entire Surface of the Body. Reported by B. 



Darrach, M. D., Resident Physician. 55 

lY. The Use and Abuse of Uterine Tents. By Horatio R. Storer, M. D., 
of Boston. 57 

Y. Remarks on some Affections of the Spinal Column. By John H. Pack- 
ard, M. D., of Philadelphia 62 

YI. Remarks on the Anatomical Diagnosis of Cancer. By J. J. Woodward, 
M. D., of Philadelphia, (Read before the Biological Department of the 
Academy of Natural Sciences of Philadelphia, Nov. 15, 1858.) . . 67 

YII. Blood-Stains. By Andrew Fleming, M. D., of Pittsburg, Pa. . . 84 



YIII. On the Occurrence of a Blowing Sound in the Pulmonary Artery 
associated with Affections of the Lung ; on the Sounds of the Artery in 
Health, and on the Effects on them and on the Heart of the Act of Inspi- 
ration. By J. DaCosta, M. D., Lecturer on the Practice of Medicine at 
the Philadelphia Medical Association 119 

IX. Notes on the Medical Topography, Climate, and Diseases of Panama, 

N. G. By Wm. P..Buel, M. D., Surgeon Pacific Mail Co. . . . 131 

X. Case of Pseudarthrosis of the Bones of both Forearms ; Failure of Brain- 
ard's Operation, and of Excision. By R. A. Kinlock, M. D., Surgeon of 
the Roper Hospital, Charleston, S. C 136 

XI. Obstinate Hemorrhage following a division of the Frsenum Linguae. By 

A. Reeves Jackson, M. D., of Stroudsburg, Monroe Co., Pa. . . . 141 



REYIEWS. 

XII. — 1. Hygiene, or Health, as depending upon the Conditions of the 
Atmosphere; Food and Drinks; Motion and Rest; Sleep and Wakeful- 
ness ; Secretions, Excretions, and Retentions ; Mental Emotions, Clothing, 
Bathing, &c. By James H. Pickford, M. D. London : John Churchill, 
New Burlington Street, 1858. 



8 



CONTENTS. 



ART. PAGE 

2. Papers relating to the Sanitary State of the People of England : being the 
Eesults of an Inquiry into the different proportions of Death produced by 
certain Diseases in different districts in England. Communicated to the 
General Board of Health by Edward Headlam Greenhow, M. D., Lecturer 
on Public Health at St. Thomas's Hospital, and Physician to the West- 
ern General Dispensary, With an Introductory Report by the Medical 
Officer of the Board (Dr. John Simon), On the Preventability of certain 
kinds of Premature Death. Presented to both Houses of Parliament by 
command of Her Majesty. 

3. Ventilation of American Dwellings ; with a series of Diagrams present- 
ing Examples of different classes of Habitations. By David Boswell Reid, 
M. D., F. R. S. E., &c. To which is added An Introductory Outline of the 
Progress of Improvement in Yentilation. By Elisha Harris, M. D., late 
Physician in Chief to New York Quarantine Hospital, &c. New York : 
Wiley & Halsted, 351 Broadway, 1858 143 

XIII. Legons sur la Physiologic et la Pathologic du Syst^me Nerveux. 

Par M. Claude Bernard, Membre de I'lnstitut, Professeur de Medecine au 

College de France, &c. &c. Paris, 1858. 2 vols. 8vo. pp. 560—520. . 156 
XIY. The Diagnosis of Surgical Cancer. By John Zachariah Laurence, 

F.R. C.S., M.B.Lond. Second edition. London : John Churchill, 1858. 

8vo. pp. 126 172 

XY. The Physiology and Treatment of Placenta Praevia. Being the Lett- 

somian Lectures on Midwifery for 1857. By Robert Barnes, M. D.. 

F. S. S., &c. &c. London : John Churchill, 1858. 12mo. pp. 208. . 176 
XYI. Sur une Fonction peu connue du Pancreas la Digestion des Aliments 

azotes. Par Lucien Corvisart. Paris, 1857-58. 
On a Function of the Pancreas but little known. By Lucian Corvisart. . 183 



BIBLIOGRAPHICAL NOTICES. 

XYII. A Practical Treatise on the Diseases of Children. By D. Francis 
Condie, M. D., Fellow of the College of Physicians, Member of the Ame- 
rican Medical Association, Member of the American Philosophical 
Society, etc. Fifth edition, revised and enlarged. Philadelphia: Blan- 
chard & Lea, 1858. 8vo. pp. 762 187 

XYIII. Diseases of the Urinary Organs. A Compendium of their Diag- 
nosis, Pathology, and Treatment. By William Wallace Moreland, M. D., 
Fellow of the Massachusetts Medical Society, &c. &c. With illustra- 
tions. Philadelphia: Blanchard & Lea, 1858. 8vo. pp. 579. . . . 190 

XIX. Illustrations of Typhus Fever in Great Britain, the Result of Per- 
sonal Observations made in the Summer of 1853, with some Remarks as 
to its Origin, Habits, Symptoms, and Pathology. By J. B. Upham, M. D., 
Formerly Assistant Physician to the Hospitals connected with the House 
of Industry at South Boston, and at Deer Island. From the Boston 
Medical and Surgical Journal. 8vo. pp. 46. David Klapp: Boston, 
1858 192 

XX. Catalogue of the Surgical and Pathological Museum of Yalentine 
Mott, M. D., LL. D., Emeritus Professor of Surgery in the University of 
the City of New York, etc., and of his son, Alexander B. Mott, M. D., 
Surgeon of St. Yincent's and the Jews' Hospital. New York : 1858. 
8vo. pp. 78 194 

XXI. Description of a New Midwifery Forceps, having a Sliding Pivot to 
prevent Compression of the Foetal Head; with Cases. By George T. 
Elliott, M. D., Physician to Bellevue Hospital, the Nursery and Child's 
Hospital, and the Lying-in Hospital, etc. etc. 8vo. pp. 24. . . . 196 

XXII. An Essay on the Pathology and Therapeutics of Scarlet Fever. By 
Caspar Morris, M.D., Fellow of the College of Physicians of Philadelphia, 
etc. etc. etc. 8vo. pp. 192. Philadelphia: Lindsay & Blakiston, 1858. . 198 



CONTENTS. 



9 



ART. PAGE 

XXIII. An Essay on Inflammation : the tenth of a Series of Articles pub- 
lished in the St. Louis Medical Journal, on " Life." By J. H. Watters, 
M. D., Professor of Physiology in the St. Louis Medical College. 8vo. 
pp. 32. St. Louis, 1858 199 

XXIY. The Pathology and Treatment of Stricture of the Urethra, and 
Urinary iFistulse. By Henry Thompson, F. R. 0. S., M. B., Lond., &c. 
Second edition, much enlarged and revised. London: John Churchill, 
1858. Octavo, pp. 426 201 

XXY. Eutherapeia; or, an Examination of the Principles of Medical 
Science, with Researches in the Nervous System. By Robert Garner, 
Surgeon to the North Staffordshire Infirmary, etc., late President of the 
North Staffordshire Medical Society, author of Papers in the Linnaean and 
Zoological Transactions, and of the Natural History of Stafford. London : 
John Churchill 203 

XXYI. Etudes sur la Monorchidie et la Cryptorchidie chez I'Homme. Par 
M. Ernest Godard, Interne des Hopitaux de Paris, Membre de la Societe 
de Biologie et de la Societe Anatomique. Extrait des Memoires de la 
Societe de Biologie, annee 1856. Paris, 1857. Octavo, pp. 164. . . 205 

XXVII. On Amputation by a Long and a Short Rectangular Flap. By 
Thomas P. Teale, F. L. S., F. R. C. S., Surgeon to the Leeds General In- 
firmary. Illustrated by engravings on wood by Mr. Bagg. London : 
Churchill, 1858. 8vo. pp. 72 208 

XXYIII. Journal de la Physiologic de I'Homme et des Animaux. Public 
sous la Direction du Docteur B. Brown-Sequard. Tome premier, Numero 
TIL Juillet, 1858 209 

XXIX. The Science and Art of Surgery: being a Treatise on Surgical 
Injuries, Diseases, and Operations. By John Erichsen, Professor of Sur- 
gery and of Clinical Surgery in University College, and Surgeon to Uni- 
versity College Hospital. Second edition, enlarged and carefully revised. 
Illustrated by 400 engravings on wood. London : Walton & Maberly, 
1857. 8vo. pp. 1040 210 

XXX. Lectures on the Principles and Practice of Physic, delivered at 
King's College, London. By Thomas Watson, M. D., Fellow of the Royal 
College of Physicians, late Physician to the Middlesex Hospital, etc. A 
new American, from the last revised and enlarged English edition. 
With additions, by D. Francis Condie, M. D., Fellow of the College of 
Physicians of Philadelphia, etc. etc. With one hundred and eighty-five 
illustrations on wood. 8vo. pp. 1224. Blanchard & Lea : Philadelphia, 
1858 211 

XXXI. A Practical Treatise on the Causes, Symptoms, and Treatment of 
Spermatorrhoea. By M. Lallemand. Translated and edited by Henry J. 
McDougall. Third American edition. 

To which is added : On Diseases of the Yesiculae Seminales and their Asso- 
ciated Organs; with special reference to the Morbid Secretions of the 
Prostatic and Urethral Mucous Membrane. By Marris Wilson, M. D. 
Philadelphia: Blanchard & Lea, 1858. 8vo. pp. 380 212 

XXXII. A Treatise on Fractures. By J. F. Malgaigne, Chirurgien de 
I'HSpital Saint Louis. With one hundred and six illustrations. Trans- 
lated from the French, with notes and additions, by John H. Packard, 

M. D. Philadelphia : J. B-. Lippincott & Co., 1859. 8vo. pp. 683. . 213 

XXXIII. A Treatise on the Yenereal Disease. By John Hunter, F. R. S. 
With copious additions, by Dr. Philip Ricord, Surgeon of the HSpital 
du Midi, Paris, etc. Translated and edited, with notes, by Freeman J. 
Bumstead, M. D., Lecturer on Yenereal at the College of Physicians and 
Surgeons, N. Y., Assistant Surgeon to the New York Eye Infirmary. 
Second edition, revised, containing a risum4 of Ricord's recent Lectures 

on Chancre. Philadelphia : Blanchard & Lea, 1859. . . . 213 



10 



CONTENTS. 



ART. PAGE 

XXXIY. The Modern Practice of Midwifery: a Course of Lectures on 
Obstetrics, delivered at St. Mary's Hospital, London. By Wm. Tyler 
Smith, M. D., Member of the Royal College of Physicians. AVith an 
Introductory Lecture on the History of the Art of Midwifery, and 
copious Practical Annotations, by Augustus K. Gardner, A. M., M. D., 
late Instructor on Obstetrics in the New York Preparatory School of 
Medicine, Author of the " Causes and Curative Treatment of Sterility," 
etc. Illustrated by 212 engravings. 8vo. pp. 760. R. M. DeWitt: New 
York, 1858 214 

XXXY. The Uraemic Convulsions of Pregnancy, Parturition, and Childbed. 
By Dr. Carl P. Braun, Professor of Midwifery, Yienna. Translated from 
the German, with Notes. By J. Matthews Duncan, F. R. C. P. E., Lec- 
turer on Midwifery, etc. etc. 12mo. pp. 182. S. S. & W. Wood, New 
York, 1858 215 

XXXYI. A System of Human Anatomy, General and Special. By Eras- 
mus Wilson, F. R. S., author of "The Dissector's Manual," "A Treatise 
on Diseases of the Skin." etc. etc. A new and improved American, from 
an enlarged London edition. Edited by William H. Gobrecht, M. D., 
Professor of Anatomy in the Philadelphia College of Medicine, Fellow of 
the College of Physicians of Philadelphia, etc. With three hundred and 
ninety-seven illustrations on wood. Philadelphia : Blanchard & Lea, 1858. 
8vo. pp. 616 222 



QUAETERLY SUMMARY 

OF THE 

IMPROYEMENTS AND DISCOYERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 
Anatomy and Physiology. 



PAGE 

Results of an extended Inquiry 
into the Quantity of Carbonic 
Acid evolved from the Lungs 
under the Influence of various 
Agents. By Dr. Edward Smith. 223 
Experiments on Digestion. By 
Dr. Geo. Harley. . . . 223 
On the Form of the Eyeball, and 
the Relative Position of the En- 



PAGE 

trance of the Optic Nerve in dif- 
ferent Animals. By Mr. Thos. 

Nunneley 224 

The Structure of the Choroid 
Coat of the Eye, and more par- 
ticularly the Character and Ar- 
rangement of the Pigmentary 
Matter. By Mr. Thos. Nunneley. 226 



Materia Medica and Pharmacy. 



New Modes of Administering 
Iodine. By M. Leriche. . . 226 
Therapeutic Properties of Sar- 
saparilla. By Dr. A, M. Adam. 227 
Formula for Jaser's Itch Oint- 
ment 227 



8. Glycerole de Gourdon and Oil 
of Cade, as a topical application 
in Eczematous and Impetiginous 
Eruptions 228 



CONTENTS. 



11 



Medical Pathology and Therapeutics, and Practical Medicine. 



PAGE 

9. On the Nomenclature and Classi- 
fication of Continued Fevers. By 

Dr. Chas. Murchison. . . 229 

10. Symptoms and Treatment of 
Diphtheria. By Dr. C. D. Kings- 
ford 234 

11. Diphtheria. By Dr. Semple. . 236 

12. On the Non-Periodical Fluc- 
tuations in the Frequency of 
Pneumonia, especially during the 
Years 1836-1856. By Dr. W. 
Ziemssen 237 

13. Clinical Illustrations of the Pa- 
thology and Treatment of Deli- 
rium Tremens. By Prof. Thos. 
Laycock 238 

14. Uses of Bleeding in Diseases. 

By Dr. W. 0. Markham. . . 240 

15. Changes produced in the amount 
of Blood-Corpuscles by the ad- 
ministration of Cod-liver Oil. By 
Dr. Theophilus Thompson. . 243 

16. Narcotic Injections in Neural- 
gia. By Chas. Hunter, Esq. . 244 

17. Use of Ox-Gall in Hypertro- 
phies. By Dr. Bonorden. . . 246 

18. Dropsy treated with Lemons. 

By Dr. Trinkowsky. . . .247 

19. Relative Yalue of the Different 
Anthelmintics in the Treatment 

of Tcsenia. By Dr. Peacock. . 247 



PAGE 

20. Hysteric Condition of Joints. 

By Mr. Barwell. . . .248 

21. Pathology of Rheumatism. By 
Dr. Francis T. Bond. . . 250 

22. Bronzed-skin Cachexia, with 
Congenital Absence of the Supra- 
renal Capsules. By Mr. J. K. 
Spencer 251 

23. Bronzed Skin and Healthy 
Supra-renal Capsules. By Dr. 
Harley 251 

24. Intestines of a Pig, which, for 
six weeks before death, had been 
fed with Typhoid Dejections." 

By Dr. Murchison. . . .252 

25. On a peculiar Black or Blue 
partial Coloration of the Skin, 
which is sometimes observed in 
Women, particularly round the 
Eyelids. By Leroy de Meri- 
court. 252 

26. Lesions and Pathological Phe- 
nomena caused by the Presence 
of Lumbrici in the Biliary Ducts. 

By Dr. E. Bonfils. . . .254 

27. Development of the Larvae of 
Dipterse in the Frontal Sinuses 
and Nasal Fossae of Man, at 
Cayenne. By C. Cocquerel. . 254 



Surgical Pathology and Therapeutics, and Operative Surgery. 



28. On Chronic Inflammation of 
the Articular Extremity of the 
Bones. By Mr. T. Bryant. . 255 

29. A rare Form of Fracture of the 
Clavicle. By M. Robert. . . 258 

30. Dislocation of the Right Fe- 
mur on the inferior part of the 
Dorsum Ilii — seven weeks' dura- 
tion ; Reduction by Dr. Reid's 
Plan. By Mr. W. J. Square. . 258 

31. Dislocation of the Forearm 
outwards 259 



32. Displacement of the Coccyx 
sideways. By Roeser. . . 259 

33. Impermeable Stricture. By 

M. Charles Phillips. . . .260 

34. Internal Urethrotomy. By 
Prof. Sedillot 260 

35. Yesico-Yaginal Fistula. By 
Dr. Geo. Buchanan. . , . 261 

36. Rupture of an enormous Ova- 
rian Cyst into the Peritoneal Ca- 
vity; permanent Cure. By C. 
Farrar. . . . . . 262 



Ophthalmology. 



37. Coloboma Iridis. By Mr. J. 

F. Streatfeild 262 

38. Iridemia. By Mr. Dixon. . 263 



39. Inutility of Depletion in Syphi- 
litic Iritis. By Mr. J. Hamilton. 264 

40. Hemeralopia treated by Azo- 
tized Yapour. By M. Deval. . 265 



12 



CONTENTS. 



Midwifery. 



41. Duration of Pregnancy. By 
Elsasser 266 

42. Port Wine Enemata as a Sub- 
stitute for Transfusion of Blood 
in cases of Post-Partum Hemor- 
rhage. By D. H. L. Williams. . 266 



PAGE 

43. Inversion of the Uterus suc- 
cessfully reduced. By Dr. F. S. 
Yerity 266 

44. On some of the Morbid Condi- 
tions which give rise to Sterility 

ia Women. By Dr. Carl Mayer. 267 



Medical Jurisprudence and Toxicology. 



45. On the Lig-ature of the (Eso- 



phagus in Animals in Toxicolo- 
gical Experiments. . . . 272 



Miscellaneous. 
46. Ozonometer. By Dr. Lankester. . 



274 



AMERICAN INTELLIGENCE. 
Original Communications. 
A somewhat remarkable Case of 



Strangulated Hernia. By Wal- 
ter F. Atlee, M. D. . . . 275 



Domestic Summary. 



On the Action of Certain Vegeta- 
ble Diuretics. By William A. 
Hammond, M. D. . . . 275 

Clinical Study of the Heart-sounds. 
By Prof. Austin Flint. . . 278 

Report of thirteen Cases of Un- 
united Fracture treated by Sub- 
cutaneous Perforation of the 
Bone. By Prof. Brainard. . 279 

Dislocation of the Fourth and Fifth 



Cervical Vertebrae. By Dr. W. 

M. Ryer 280 

Changes of the Blood-Cells in the 

Spleen. By Dr. Henry Draper. 281 
The extent to which Ether should 

be used in Midwifery. By Dr. 

Cotting 281 

Reduction of an Inverted Uterus 

of Fifteen Years' duration. By 

Prof. White 282 



Obituary Record. — Timothy Phelps Beers, M.D. 



283 



THE 

AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JANUARY 1 8 5 9. 



Art. I. — On the Minute Structure of the Hepatic Lobules, particularly 
v:ith reference to the Relationship between the Capillary Bloodvessels, 
the Hepatic Cells, and the Canals which carry off the Secretion of the 
latter. By H. D. Schmidt, M. D., of Philadelphia. (Illustrated with 
83 Figures.) 

Several months since, in examining the microscopical structure of the 
liver, I obtained very unsatisfactory results from a mere superficial examina- 
tion. The great discrepancy of opinion existing among the best histologists 
of the present day in regard to the minute anatomy of this organ attracted 
my attention, and, wishing to satisfy myself on this point, I determined to 
make it a special subject of investigation. 

The modes I adopted for this have perhaps enabled me to work with 
greater advantage than others. 

When we consider the complex structure of this organ, we need not 
wonder that the best microscopists have been baffled in the attempt to un- 
ravel its minute anatomy; though it is in some instances astonishing that 
their opinions should be so widely different 

The following pages are devoted only to the consideration of the minute 
structure of tJie hepatic lobule, or the relationship existing between the 
capillary bloodvessels, the hepatic cells, and those passages or canals des- 
tined to carry off the secretion of the latter. 

Although I have examined the liver of several animals, yet I preferred 
for special investigation those of the sheep and hog. The liver of the latter 
has generally been recommended as being most suitable for investigation : 
but for injecting (although the difference is slight) I prefer that of the 
sheep. The portal vein and hepatic duct in the latter (like in that of man) 
No. LXXIIL— Jan. 1859. 2 



14 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

braccli out at acute angles, and consequently olfer less resistance to the 
])assage of the injection, than in the hog in which the branches of the 
interlobular vessels mostly come off at right angles with the periphery of 
the lobule, so that a greater pressure is required to send the injection into 
tbera. 

Since commencing these investigations T have endeavoured to obtain 
healthy human livers, but have as yet succeeded in only one instance. In 
this, unfortunately, the vena cava had been cut off so close to the organ, 
that it prevented me from throwing an injection into the hepatic veins ; 
nevertheless, I injected the other vessels, and the examination proved satis- 
factory, though I did not consider the injection sufficiently perfect to serve 
for thorough investigation. I shall therefore postpone to a future period 
the investigation of the microscopical anatomy of the human liver. 

Before proceeding further, it may perhaps be useful to cite the views of 
different observers on the subject. 

E. H. Weber^ has been led to the conclusion that the bile-ducts form a 
network, the meshes of which fit exactly in that of the capillary bloodves- 
sels of the liver. Both these networks are interwoven in such a manner 
that the one fills up the interspaces left by the other. The bile-ducts no- 
where anastomose with the blood-carrying capillary system, but both classes 
of canals touch each other only on the sides of their walls. He further 
remarks that the rows of cells in the liver are true canals (this he proved 
by injections), and these form a network, the tubes of which are of the same 
diameter as the finest bile-ducts injected by him. 

Kruckenberg,^ who also injected a network of bile-ducts interwoven 
with the capillary blood system of the liver, is more cautious in his expla- 
nation than Weber. He believes that the hepatic cells lie in reticularly 
arranged tubes (finest bile-ducts), the walls of which, being very thin, were 
invisible. The latter, from being torn so easily, and on account of their 
reticular arrangement and intimate interweaving with the capillaries, could 
not be demonstrated. At the same time he refers to the uriniferous tubules, 
which, formed by the union of peculiar cells by means of a structureless 
membrane, have not always a visible tube. 

Theile^ also believes in the existence of a membrana propria, in which 
the liver-cells lie. But this is only hypothesis, as he has not seen it. Ac- 
cording to him, the latter fill up the membrana propria, for which reason 
the injecting matter penetrated to the periphery of the lobule, but not into 
the tubes themselves. 

Backer* even pretends to have seen this membrana propria, which by 
Kruckenberg and Theile is only hypothetically thought to exist. He de- 
scribes it as a structureless membrane, covered by longitudinal fibres, which 



' Geiiacli's Gewebelelire, II. Auflage, p. 329. 
9 Ibid., p. 330. 



2 Ibid., p. 330. 
4 Ibid., p. 330. 



1859.] 



ScnMTDT, Minute Structure of Hepatic Lobules. 



15 



only becomes invisible by drying, or when the cells (by imbibition of liquid) 
swell up, and thus lie close to the membrana propria. 

R.EZius and Weja^ make statements to the same effect. 

Krause^ declares that the bile-ducts take their starting-points from vesi- 
cles or true acini. These acini ought not to be confounded wath the lobules 
of the liver; but they are, according to him, small round or slightly oval 
bodies, which by reflected light have a yellowish-gray appearance. They 
inclose six or eight hepatic cells, and form the greater part of the mass of 
the lobule. He also thinks that these small bodies, as they w^ere not ob- 
served by others, had been looked upon as very large liver-cells. 

Lereboxjllet,^ in regard to the arrangement of the biliary cells, says : — 

" The biliary cells are joined by their ends so as to form longitudinal series 
which converge towards the centre of the lobule. These longitudinal series 
are united by shorter transverse ones, so as to represent a network with 
meshes, polygonal or rounded, at the periphery of the lobule, and elongated 
towards its central part. 

Each thread of this network is double — that is, formed by two ranges of 
cells, which touch at their sides, and leave only a linear interval between 
them. But these two ranges of cells are only in juxtaposition, separating 
easily by the slightest traction, 

" The cells w^hich constitute the series are, on the contrary, adherent to 
each other. Hence we frequently see simple series of cells yet adherent 
after tearing a minute piece of the substance of the liver. 

These series or chains of cells do not form tubes, as w^as supposed by E. 
H. Weber. The cells which compose them do not open into each other, but 
are, on the contrary, perfectly disthict and independent. 

" The network formed by the double ranges of cells pervades the whole 
thickness of the lobule from the perilobular vessels to the central one. 
Hence it is inaccurate to speak of the secretion taking place exclusively at 
the periphery of the lobule. The meshes of the network of cells are filled 
by the bloodvessels of the lobule. 

" The double threads of the biliary network are probably surrounded by 
a proper membrane, which would constitute the basement membrane of the 
secretory tubes; but this is so adherent to the walls of the bloodvessels, as 
to render it impossible to prepare and demonstrate it in such a manner as 
to show that the included biliary cells are only epithelial. Therefore, in the 
natural state, these secretory tubes wdthin the lobule would be full — that is, 
entirely occupied by the secretory cells; and hence their cavity is simply 
linear. 

" When we succeed in throwing an injection into these biliary passages, 
the injected matter distends the linear intervals just described, compresses 
the cells, and gives the appearance of a rete of capillary ducts, which takes 
the place of the network formed by the double ranges of cells. 

"The capillary biliary ducts of authors are, then, produced mechanically 
by the injection. These canaliculi have, indeed, no proper w^alls, the injected 
matter being in immediate contact wnth the secretory cells. 

"The rest of the lobule is occupied by a vascular rete, formed by the por- 

' Gerlack's Gewebelehre, II. Auflage, p. 330. « Ibid., p. 331. 

3 Medical Examiner, vol. x. (1854) N. S., p. 206 et seq. 



16 



Schmidt, Minute Structure of Hepatic Lobules. [Jan. 



tal vein and tlie radicals of the hepatic vein. The meshes of this network 
adapt themselves exactly to the threads of the biliary rete, and vice versa, 
so that the two are closely interlaced. The mean diameter of the threads 
forming the meshes, and of the meshes themselves, in either network, is 
0.15 of a millimetre." 

Further on, he states that " the biliary canals which have lobules, are 
always multiple. They arise from all points of the surface of the lobule, 
and after having frequently united with each other like the roots of a tree, 
leave the lobule and form one or more ducts, which, with the corresponding 
trunks of the portal vein and hepatic artery, are surrounded by a fibrous 
sheath, the capsule of Glisson." 

Leidy,* in his researches into the comparative structure of the liver, in 
speaking of the biliary tubes, says : — 

"The lobules are composed of an intertexture of biliary tubes {pori 
hiliari), and in the areolse or interspaces of the network the bloodvessels 
ramify and form among themselves an intricate anastomosis, the whole 
being intimately connected together by a combination of white fibrous and 
yellow elastic tissue." 

"In structure, the biliary tubes correspond with those of the interverte- 
brata, consisting of cylinders of basement-membrane containing numerous 
secreting cells, and the only difierence exists in the arrangement ; the free 
tubes of the lower animals in the vertebrata becoming anastomosed, or 
forming an intertexture. The tubuli vary, in size in an unimportant degree, 
in different animals, and also in the same animal, being generally from two 
to two and a half times the diameter of the secreting cells. The tubes of 
one lobule are distinct from those of the neighbouring lobuli, or only com- 
municate indirectly by means of the trunks or hepatic ducts originating 
from the tubes and lying in the interspaces of the lobuli. The secreting 
cells are irregularly angular, or polygonal in form, from mutual pressure, 
and line the interior surface of the tubes. They vary in size in a moderate 
degree in different animals and also in the same animal, appearing to de- 
pend upon certain conditions of the animal and liver. The colour is light- 
yellowish, or brownish when in mass; the other and darker colours of the 
liver appearing to depend upon the blood in the organ. They contain a 
finely granular matter, oil-globules, a granular nucleus, and a transparent 
nucleolus." 

Beale,^ one of the latest observers on the minute structure of the liver, 
and to whom I shall have occasion to refer again, maintains : That the 
smallest biliary ducts are directly continuous with the tubular network of 
basement-membrane in which the liver cells lie ; for, in favourable specimens, 
injection, forced in from the duct, will pass into every part of the tubular 
network, even quite to the centre of the lobule. It is possible to inject the 
capillary network in the same preparation as that in which the ducts and 
cell containing network are injected. 

Kolliker"' remarks, that in all his continued search, he has never dis- 

1 American Journal of the Med. Sciences. New Series. Vol. xv. p. 18. 

2 Beale, On the Anatomy of the Liver, 1856, p. 54. 

3 KoUiker's Handbuch der (xewebelehre des Menschen, 1852, p. 421. 



1859.] Schmidt, Minute Structure of Hepatic Lobules. IT 

tinctly observed a direct connection of the finest ducts with the network of 
hepatic cells, which, he continues, is not surprising in considering the soft- 
ness of the parts in question; yet, leaves an opening in the minute anatomy 
of the liver which can scarcely be closed by hypotheses. As such, he offers 
the supposition that the finest ducts come in direct opposition with the 
columns of the network of hepatic cells, and thus have their orifices closed. 
He believes that such connections exist in no very great numbers at the 
periphery of the hepatic islets, which might be inferred from the scanty 
number of the finest branches of the hepatic duct. 

The bile, he says, must be transmitted outwards from cell to cell, for the 
possibility of wdiich process he refers to the physiology of vegetables. 

Yiews, similar to those of Kolliker are entertained by C. Handfield 

JONES.^ 

This observer, in regard to the excretory ducts, states : That the liver in 
all vertebrate animals may be regarded as consisting of a secreting paren- 
chyma and excretory ducts. The size of the excretory apparatus bears 
only a small proportion to that of the secretory. 

These two portions of the liver are not continuous with one another, but 
disposed simply in relation of juxtaposition. 

The action of the liver seems to consist in the transmission of the bile 
as it is formed from cell to cell, till it arrives in the neighbourhood of the 
excretory ducts by w^hich it is absorbed. This action is probably slow, 
and very liable to be interfered with, contrasting remarkably with that of 
the kidney, where a particular apparatus is added to insure completeness 
and rapidity of action. 

In a second paper, written some years afterwards,^ he says that farther 
observations confirm him still in the opinion he formerly expressed. 

Gerlach,^ from observations made on injected livers, comes to the con- 
clusion that the intralobular ducts, after having arrived at the lobule, send 
off small branches, 0.002 to 0.004 of a millimetre in diameter, which, after 
having formed a free anastomosis at the periphery of the lobule, terminate 
in intercellular passages or free spaces, left between the cells. He remarks,-^ 
that the sudden transition of true tubes into intercellular passages, where 
the structureless membrane of the tubes ceases abruptly, is certainly a very 
uncommon phenomenon and altogether wanting of analogy. But the re- 
sults of his numerous injections point it out so distinctly, and exclude 
every other explanation so perfectly, that he does not think proper to 
change his views. As a farther confirmation, he observed the termination 
of a small duct, belonging to the peripheral anastomosis, in a specimen of 
injected human liver. Here, he saw, with the greatest distinctness, that it 
terminated by an open mouth, in opposition to the views of H. Jones. 

' Philosophical Transactions of the Rojal Society of London, 1849, p. 132. 
2 Ibid., 1853, p. 2. 3 Gerlach's Gewebelehre, II. Auflage, p. 333. 

* Gerlach's Gewehelehre, II. Auflage, p. 336. 



18 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

Since I commenced this article I have met with the valuable paper of M. 
Natalis Guillot, "On the Structure of the Liver of "Vertebrate Ani- 
mals."^ The results of his extensive researches, which were made ten 
years ago on injected specimens, are almost the same as those obtained bj 
myself. The only difference is, that by means, of superior accessory instru- 
ments my conclusions were drawn not only from observations on well in- 
jected specimens, but also from the fragments of fresh livers from divers 
animals. 

Guillot, in speaking of the termination of the hepatic duct, says : — 

"After having followed the ramifications of the portal vein and the he- 
patic artery, and having surrounded them with numerous loops, and after 
having connected themselves a thousand times by the finest anastomoses, 
the biliary vessels (ducts) are replaced, or, in other words, continued by an 
order of canals, the traces of which may be recognized in the middle of the 
mass of hepatic cells. 

" It is, to the middle of the islets,'^ surrounded by the anastomoses of the 
capillaries of the blood that this collection (ensemble) of biliary canals may 
be seen ; they can be traced to this place, not only in fishes, reptiles, and 
birds, but also in mammiferous animals, and in the liver of man. 

"They cannot be distinguished without first being made visible by means 
of injection. Without this indispensable precaution, the finest slices of the 
liver of fish, bird, or mammiferous animal, will give no evidence of the ex- 
istence of any sort of regular canals."^ 

' Annales des Sciences Naturelles. Troisieme serie. Zoologie. Tome ix. p. 163. 

2 Groups of six or eight cells contained within the meshes of the capillary blood- 
vessels, hut connected with each other. 

3 As I consider the observations of Guillot important to the confirmation of my 
own, I will quote his own words : Annales des Sciences Naturelles, p. 132. 

" Ayant cherche ^ savoir si cette maniere de voir etait exacte, elle m'a, au con- 
traire, semble fort douteuse. Quelsqu' aient ete les animaux soumis a mes ob- 
servations, nulle part I'agregation de ces particules (cells) ne m'a paru etre 
reguliere. 

Lorsque les particules du foie des animaux vertebres sont reunies les unes aupres 
des autres, I'irregularite des points de contact, par lesquels elles se touchent, ap- 
parait avec une grande evidence. On est ensuite frappe du caractere singulier des 
fragments observes, lorsqu'on a fait aucun elfort capable des dissocier les elements 
qui les composent, et de les eloigner les uns des autres. lis forment alors une agre- 
gation tellemens serrees, qu'il parait impossible a la bile ou au sang de trouver un 
passage entre ces particules. 

Cette apparance est commune a tons les animaux. 

Ceux d'entre eux qui ont peris par suite d'une hemorrhagic offrent au plus haut 
degree cette contiguite des particules du foie ; chez ceux, au contraire, dont la mort 
a ete lente, il reste encore une assez grande quantite de sang dans I'organe pour 
donner a la matiere des caracteres entierement opposees. Certain details apparais- 
sent alors, obscure encore, il est vrai, mais trop interessants pour ne pas meriter une 
serieuse attention. 

Dans ces organes penetres d'une certain quantite de sang, ce liquide est encore 
contenu dans les canaux, au travers desquels il circulait pendant la vie, et c'est 



1859.] 



Schmidt, Minute Structure of Hepatic Lobules. 



19 



It will be seen from the above, that the views of the majority of observ* 
ers have been based mainly on hypotheses or analogy. I shall, therefore, 
be very guarded in expressing any opinion not founded on observation, and 
shall leave the rest to the judgment of men more experienced on the subject 
than myself. 

While, with Guillot, Gerlach, Beale, and others, I consider a good injec- 
tion absolutely necessary for a thorough investigation of the structure of the 
liver, yet I do not think that we should confine ourselves altogether to this 
mode of investigation. We ought also assiduously to examine the tissue of 
the organ in its fresh state ; but if the choice were left to me between the 
two modes of investigation, I would unhesitatingly give the preference to 
the former. We are surely better enabled to distinguish the relationship of 
the vessels, canals, &c., in a thin, transparent slice of the organ, when they 
are well filled with colouring matter, than on a fragment of soft tissue which 
mostly shows only a confused mass of ducts, capillaries, cells, fibrous tissue, 
&c. Although after long practice and study we succeed in distinguishing 
readily a capillary, duct, &c., yet it is extremely difficult, after these delicate 

precisement dans les endroits ou les globules sanguins sejournent que les parti- 
cules du foie cessent de se toucher. 

Par iTn examen attentif des parties oul'on observe les globules sanguins, on peut 
deja Hve conduit a distinguer, certains canaux regulierement disposes dans I'epais- 
seur de la matiere. 

Les traces regulieres de ces canaux n'indiquent-elles pas deja que les particules 
du foie, appliquees les unes contre les autres dans quelques circonstances sont 
forcees, dans d'autres cas, de s'eloigner de celles qui les toucheraient si I'organe 
etait prive de sang ? 

Negligeant maintenant d'autres considerations, je ne m'attacherai qu'a faire 
remarquer I'evidence avec laquelle ces canaux apparaissent, lorsqu'on examine, 
ineme sans de tres forts grossisements, des parcelles de foie injectees avec I'eau 
coloree, I'essence de terebentliine ou meme le mercure. lis effacent, et disparais- 
sent des ques ces liquides se sont eooulees, et les particules redeviennent alors 
comme auparavant exactement appliquees les unes sur les autres. C'est princi- 
palement a ces etudes que sont utiles les injections de matieres diffluentes. 

P. 163. Apres avoir suivi les ramifications de la veine porte et de I'artfere, les 
avoir entourees d'anses numbreuses, apres Hre unies mille fois par des anastomoses 
de plus en plus fines, les vaisseaux biliares sont remplacees ou mieux continuees 
par un ordre de canaux dont on reconnait les traces au milieu de la masse des 
particules du foie. 

C'est jusqu'au milieu des ilots entourees par les anastomoses des canaux san- 
guins que Ton decouvre cet ensemble de canaux biliaires ; on peut les suivre jusqu' 
a cet endroit non seulement dans les Poissons, les Reptiles et les Oiseaux, mais 
encore dans les animaux mammif^res et sur le foie de I'Homme. 

On ne peut les distinguer sans les avoir mis en evidence a I'aide d'une injection 
prealable. Sans cette precaution indispensable, les tranches les plus minces du 
foie d'un Poisson, d'un Oiseau ou d'un animal mammifere, ne laisseraient sup(jou- 
ner I'existence d'aucune espece de canal regulier. Les particules du foie serraient 
alors immediatement appliquees les unes sur les autres." 



20 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

parts, have been roughly torn and displaced by means of needles, to detect 
the relative position they held before their separation. 

As a good, minute injection of the organ is so important for its investi- 
gation, it may be proper here to make a few remarks on this subject. 

If I may judge from the expressions of different authors, it seems 
that minute injections have often been undervalued as a means of micro- 
scopic investigation. The reason for it is very obvious. To acquire facility 
in making injections requires much practice, and the expenditure of more 
time than most persons can devote to it. Besides this, it is a tedious and 
vexatious process. Frequently a small vessel will rupture, and the colouring 
material be thrown over the person of the operator. It is also expensive, 
as a great deal of material is wasted before experience enough is acquired 
to have the process perfectly under control. Many disappointments are 
met with ; and if the injector be not possessed of a good share of persever- 
ance, he will certainly become discouraged and give up the matter. Further, 
to be a skilful injector requires not only some mechanical skill and judg- 
ment, but also manual dexterity; which, unfortunately, all men of science 
do not possess. I have frequently seen profound students using their fin- 
gers as awkwardly as a child. Experience, and manual dexterity, are 
therefore required to make good injections; and I have no doubt that 
those anatomists renowned for their beautiful injections, as Berres, Hyrtl, 
and others, possessed both. 

To make a good injection, the pressure should be applied very gradually. 
In injecting a liver, I am in the habit of first injecting the duct, then the 
artery, and lastly the veins. With one exception, I have always injected the 
entire liver, although small portions may be used. In order to inject the 
organ perfectly, it should be healthy and uninjured. 

The material to be injected is a most important consideration. I believe 
that gelatine has been a favourite vehicle of many anatomists for the con- 
veyance of the colouring matter. In former experiments I have frequently 
used it; but there are inconveniences attending it, and now I never em- 
ploy it, except for special objects. For instance, the organ to be injected 
must be kept at the same degree of temperature required for retaining the 
injecting matter in a fluid state; besides this, the colours cannot be readily 
mixed with it, as few of them are soluble in water; it is also very inconve- 
nient to strain the material. 

Ether I have found to be the most easily managed liquid. It is one of 
the most penetrating of fluids, but by itself is of too low a specific gravity 
to carry a heavy substance like vermilion ; therefore it is necessary to give 
it a body. For this purpose the resins, wax, fats, &c., may be used, but the 
best material is Canada balsam; this is an excellent vehicle for carrying the 
colouring matter into the minute biliary vessels. I am unable to state the 
precise density which answers best. My mode of determining this is by let- 
ting some drops of it fall on a piece of glass; it ought to evaporate in about 



1859.] 



Schmidt, Minute Structure of Hepatic Lobules. 



21 



half a minute, and leave a body which may be tested by scratching it with 
a needle. After the solution is brought to its proper density, it must be 
filtered through good filtering paper, for any hquid thin enough to pass 
the paper will also penetrate into the capillaries. Besides the Canada 
balsam, I use wax. The density of this solution is regulated by the filtering 
paper; if it is too dense, the superfluous wax remains behind. This solu- 
tion always looks clear when well filtered. If we use the solution of Canada 
balsam alone for the injections of tissues to be dried and then cut in thin, 
transparent slices, they become too hard; to avoid this, I usually mix the 
solution of balsam and that of wax, in equal proportions, as the wax 
gives softness and pliability to the preparation. But for the injection of 
the biliary ducts I use the solution of Canada balsam alone, as the wax is 
granular. 

Another important point in regard to the injecting matter is the con- 
sideration of the colour to be mixed with it. The finest colours are those 
ground up with linseed oil, and used by artists. By the process of tritura- 
tion which they undergo they are thoroughly mixed with the oil, which is 
very soluble in ether. 

My only method of testing the density of the coloured liquid is by slightly 
shaking the bottle in which it is contained, and then observing whether the 
colour is dense enough to remain upon the glass for a few seconds, before 
falling to the bottom. 

For the injection of the bihary ducts I use only half the amount of 
colouring matter for filling the small ramifications, and afterwards inject a 
denser liquid, which, by pressing upon the former, forces it into the smaller 
passages. The colour I prefer for the ducts is chrome-yellow. After a 
little practice the operator becomes familiar with these particulars, and dis- 
tinguishes them without losing much time in weighing and measuring. 

After a liver has been well injected, it should be dried in the air for three 
or four fine days, so that the ether may evaporate, then be cut into slices 1 
or 1^ inch thick. Without this precaution the peritoneal covering pre- 
vents the evaporation of the watery parts, and thus a longer time is required 
for drying. 

In regard to the mode of making the best sections, I refer to the descrip- 
tion of the apparatus for making microscopic sections. The sections, if 
well made, must be transparent. They should be examined in some liquid, 
as water, glycerine, &c. 

The tissue of the liver is no more altered by the action of ether than by 
that of alcohol. The former coagulates the albumen, giving a more 
granular appearance to the cells. In fine sections the nucleus is difficult 
to recognize, but I have sometimes seen it. The watery parts of the tissue 
lost in the process of drying, are regained when the tissue is immersed 
in liquid for a short time, so that it is as good for examination afterwards 
as before. Some may object to the examination of specimens which have 



22 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

been dried; but the relationship of the structure is not altered. If the cell 
loses its watery parts, the capillary or the duct does so likewise; both will 
imbibe in like proportion, the amount of colouring matter remaining the 
same. 

Having now given the necessary directions for the injection of the organ, 
I shall proceed to the consideration of the anatomy of the hepatic lobule. 

The views I had been taught, and which I still entertained when com- 
mencing these investigations, were, that the cells lay within a network of 
tubes of basement membrane, continuous with the branches of the duct; 
and, reasoning by analogy, these views seemed to me probable, for I could 
not believe that the bile was transmitted from cell to cell until it reached 
the open or closed mouth of the branches of the hepatic duct. 

When I examined specimens of the first liver injected by me, which was 
that of a cat, I noticed a reticular arrangement of the colour (chrome-yel- 
low) which I had thrown into the hepatic duct. This examination was 
merely a superficial one, and made on opaque pieces by reflected light. 
Although my object had been to inject the network of tubes of basement 
membrane, yet I was much surprised at my early success, and the idea sug- 
gested itself that a duct had been ruptured and the colour had entered into 
the bloodvessels. After some reflection, I saw the improbability of the 
liquid having ruptured a duct from within, and then perforating the wall 
of a bloodvessel from without. In several other injections I obtained the 
same results; but all these examinations were made with reflected light, for 
I had not yet made a thorough examination of transparent sections with 
transmitted light. I also examined fragments of fresh livers ; and yet, with 
all my constant efforts, I could never discover the slightest evidence of the 
existence of the tube of basement membrane. The rows of cells I always 
met with seemed to be held in close apposition by some invisible agent. I 
saw capillaries with their nuclei, ducts lined by an epithelium, fibrous tissue, 
&c., but no membrana propria. 

I met with a similar disappointment in examining fine sections. The 
rete injected had not the appearance of one formed by tubes large enough 
to contain hepatic cells. I noticed, too, that this injected rete corresponded 
mostly with the course of the capillaries, only crossing the latter here and 
there; which observation led me to think that this rete was an independ- 
ent one. 

Further observations on injected and fresh specimens of liver have con- 
firmed opinions which I will state in substance before proceeding to details, 

viz : Tico capillary nelworks, each independent of the other, exist in the 
lobule of the liver; the one, commencing at the periphery of the lobule, 
from the smallest branches of the portal vein and hepatic artery, and 
ending in the centre in those of the hepatic vein, is destined for the circu- 
lation of the blood brought there by the portal vein and hepatic artery; 
the other, commencing independently in the centre of the lobule, near the 



1859.] 



Schmidt, Minute Structure of Hepatic Lobules. 



23 



intralobular vein {branch of the hepatic vein), and ending in the smallest 
branches of the hepatic duct, is most probably destined to carry off the 
secretion of the cells. The cells lie ivithin the meshes of these two net- 
works, but seem to be especially held in their position by their adhesion 
to the netiDork destined for the secretion. 

These fine biliary vessels are in reality biliary capillaries ; but, for the 
sake of contradistinction from the capillaries that carry blood, I shall call 
them biliary tubules, until my observations have been confirmed by others, 
and a better name proposed. 

The observations made on injected specimens shall be first considered. 

In sheep, as in man, the lobules of the liver have no definite borders, 
hence it is difficult to say where one ceases and the other commences ; we 
can only judge by the relation and proximity of the branches of the dif- 
ferent vessels. The intralobular branch of the hepatic vein runs at a right 
angle with the portal vein, which is accompanied very closely by the hepatic 
duct. The portal vein sends off branches which ultimately ramify into the 
capillary system ; similar branches of the hepatic duct pass into a system of 
their own, the boundaries of which extend to the intralobular vein. The 
capillaries of the duct (biliary tubules) are mostly seen lying alongside of 
those of the portal vein, except when they cross each other to form an 
interlacement; the cells lie in the interspaces. 

PI. I. Fig. 1, which represents a thin transparent section of a part of the 
lobule of the sheep (viewed by transmitted light), conveys a good idea of 
the relationship existing between the branches and capillaries of the portal 
vein and those of the duct. Here, we see at {a) the transverse section of 
a branch of the former, and at (6) one of the latter ; both send off smaller 
branches, and after having become capillaries, interlace themselves ; between 
and around the two vessels the fibrous tissue can be seen, belonging to the 
capsule of Glisson. 

In the liver of the hog (PI. I. Fig. 2) each lobule is enveloped by a 
capsule of fibrous tissue ; which by some anatomists is supposed to be a 
continuation of the capsule of Glisson. The branches of the portal vein, 
after entering between the lobule, divide into numerous other smaller ones, 
which surround the capsule; these again give off shorter ones, which pene- 
trate the capsule to form the interior capillary network. The branches of 
the duct lie close to those of the portal vein, and are given off exactly in 
the same manner. The hepatic artery also closely follows the vein and 
surrounds it with a network of its branches ; its finest ramifications, after 
having penetrated the capsule, are blended with the blood carrying capil- 
laries of the lobule, and thus the blood of both vessels is mixed within the 
latter. I have often seen the capillary network, of entire lobules, filled 
with the colour injected through the artery. 

In the liver of the sheep I have noticed very extensive anastomoses of 
the small branches of the duct around the branches of the portal vein. 



24 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

It is believed by some, that tlie meslies of the capillaries are more oblong 
near the intralobular vein than the portal branches, but I find little differ- 
ence between them ; and in some instances, in the liver of the sheep, I have 
observed directly the reverse. The capillary network seems to be formed 
(at least in the hog) by more or less strait vessels, radiating from the 
intralobular vein as a common centre towards the periphery of the lobule ; 
these vessels are connected with each other by shorter transverse branches, 
and thus the rete is formed. In fresh specimens I have often observed 
capillary vessels as long as six or eight liver cells with the remnants of the 
broken transverse branches adhering to them. The cells I believe to be 
arranged in the same manner, that is, generally in single rows, radiating 
from the centre and connected by shorter ones. Of course, these radiating 
vessels and rows of cells, arising from the periphery, cannot all run to the 
centre, but the greater number of them are lost between the others. 

In fine transparent sections I have observed a tendency to split in the 
lobules of the liver of the hog ; usually this commences at the centre, ex- 
tending towards the periphery, though it sometimes occurs from one peri- 
phery to the other, through a small portion of the lobule. Searching for 
the cause of this in entire lobules, I found it to be fine transparent lines, 
bounded by fine double contours, and running mostly from the centre of the 
lobule towards a branch of the portal vein ; other finer lines, with the same 
contours, are seen extending into them ; the course of both are usually ser- 
pentine. The capillaries can be seen running across these lines. This has 
been observed in hundreds of lobules, for my apparatus enables me to make 
sections, containing about eighty lobules, with great rapidity. In tracing 
one of these lines, I observed in one instance that it passed from one 
lobule to another through the fibrous tissue of the capsule; in some cases 
more than one is seen in the same lobule. (In examining sections of the 
liver of sheep, treated with a weak solution of potassa, which renders them 
transparent, I observed empty vessels running towards the vein. At first 
I supposed them to be lymphatics, until I noticed others as large as the 
finer branches of the portal vein, which made me suspect them to be unin- 
fected vessels.) 

That the above-mentioned fine transparent lines in the hepatic lobule of 
the hog are not nerve fibres, seems evident to me, since the course of a 
nerve is more wavy than these lines. Are they then the ultimate branches 
of the lymphatics which have not yet been observed ? I merely mention 
this for the purpose of directing the attention of other observers, not hav- 
ing examined it sufficiently to form an opinion myself. 

The biliary tubules can also be recognized in specimens in which only 
the capillaries have been injected. If such a section is treated with a weak 
solution of potassa, which makes it expand, fragments of fine vessels can 
be seen at the sides of the capillaries, often traversing the latter. Such a view 
is represented in PI. I. Fig. 4. If these double contours extended entirely 



1859.] Schmidt, Minute Structure of Hepatic Lobules. 25 

along tlie sides of tlie capillaries, they might be taken for their walls ; as it 
is, I suppose them to be nothing but the fragments of uninjected biliary 
tubules, especially as we find them here and there crossing the capillaries. 
The dark places in the vessels are caused by the presence of colouring 
matter. 

I have already advocated the mode of investigation by injection. But 
as some may consider the injected biliary tubules as nothing more than 
extravasations between the cells, I will adduce further considerations in 
support of my views. 

An extravasation is very readily distinguished from a perfect injection 
by one accustomed to the examination of minute injections. It is an infil- 
tration into the tissue, caused by the rupture of one or more of the capil- 
laries, and looks very irregular. The interspaces between the capillaries 
are filled up by the colouring matter, if the extravasation has taken place 
to any extent; the material sometimes forms small curves, but these can 
never be mistaken for a regular arrangement of vessels; PI. II. Fig. 9 
represents the aspect of a duct whose branches are ruptured and the colour 
extravasated. Every one can recognize the very great contrast between 
it and Fig. 3, PI. L, which represents a part of a thin section of the liver 
of the hog, in which only the duct has been injected. Here the regular 
arrangement of the injected biliaiy tubules is too evident and striking 
to be mistaken for an extra vasatiqn. If the extravasation is slight, it has 
an aspect somewhat like Pig. 8, PI. II. This has probably been the case 
with GerlacKs injections of the ducts, which led him to think that these 
canals had no walls of their own, but were intercellular spaces. If the 
drawing, accompanying the extract from LerebouUeVs researches on the 
intimate structure of the liver, in the lledical Examiner, be a true copy, 
I can only consider it the representation of a complete extravasation into 
the interspaces of the capillary network of the lobule. The injected 
specimens examined by C. H. Jones seem also to have been imperfect. In 
the injections of the livers of the pig, of which he speaks,^ the fault, most 
probably, was in the material, which consisted either of a bad vehicle con- 
tained with too much colouring matter, preventing it from penetrating 
into the biliary tubules. The trials which he afterwards made"^ on only 
two livers with the acetate of lead, were not sufficient for drawing any 
conclusion. The acetate of lead is not a proper material for injections : 
it formed, as he says, a precipitate with the albuminous plasma between 
the cells, but only after having ruptured the biliary tubules. The injecting 
material should be as neutral as possible. 

Yery slight pressure is required for the injection of the biliary tubules ; 
less than that for injection of the bloodvessels. 

In regard to the theory of the cell containing network of tubes of base- 



' Phil. Trans., 1849, p. 125. 



2 lb., 1S53, p, 2. 



26 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

ment membrane, I would observe that if such an arrangement existed in 
the hepatic lobule, and the tubes of this were injected, a section of it would 
give the appearance represented in diagram PI. II. Fig. 7. The injected 
rete, instead of being alongside the capillaries, would occupy the middle of 
the meshes and send little branches for a short distance between the cells. 
Besides this, there is another very important fact, which seems to have 
been entirely overlooked; this is in regard to measurement. The diameter 
of a cell is twice or three times that of a capillary. Now, the interspaces 
of the capillaries in a thin section of injected liver are not large enough to 
admit more than one cell ; again, the cells in fresh specimens are mostly 
met with, arranged in single rows ; we seldom see them double. It might 
be said that the capillaries are distended by the colouring matter ; but 
when this is the case, the interspaces will be seen almost obliterated by the 
distension of the vessels. If, on the other hand, the capillaries are but 
moderately filled, it might be said that the cells collapse and shrink away. 
This view, however, cannot be sustained, because if the cells shrink away, 
the ethereal solution in the capillaries will evaporate and leave nothing 
behind but the colouring matter and other solid elements of the solution. 
This can be well seen in PI. I. Pig. 4, where both capillaries and cells have 
expanded again by the action of the potassa; the colouring matter not being 
sufficient to fill up the vessels. PI. I. Pig. 6, which represents the outlines 
of the capillaries of a thin section, treated by a weak solution of potassa, 
shows this also. PI. I. Fig. 5 represents two cells from the same piece ; they 
overlap each other, and are too large to be admitted through some of the 
meshes. 

Additional confirmation of the views above expressed, have been ob- 
tained by observations on fragments of the fresh liver, in which I demon- 
strated the existence of the biliary tubules very satisfactorily to myself in 
different modes, as follows : — 

When we take a small fragment ' of liver, tear and separate its con- 
stituents on a glass slide, and then place it under the microscope for 
examination, it is only by accident we meet with a favourable exposition 
of capillaries, ducts, &c. ; and, even then, it is no easy matter to observe in 
this confused mass, the true relationship of the elements of which it is 
composed. But if we can separate these parts by means of fine needles, 
and in the mean time observe all the details of the process, points are 
brought into view, which before were hidden to our closest observations. 

The Microscopic Dissector, I invented for this purpose, has enabled me 
to make such observations. (See description of this instrument.) 

For this purpose the liver of the hog is especially suitable. In cutting 
through one of its lobules, and taking a small fragment from its contents, 
we are certain not to have fibrous tissue mixed with the cells and capil- 
laries, for the capsule of Glisson does not extend into the interior of the 
lobule. To corroborate this, I will cite the opinion of Beale, who is one 



1859.] 



Schmidt, Minute Structure of Hepatic Lobules. 



21 



of the latest writers on this subject. In speaking of the capsule of Glisson, 
he says :^ — 

" 3Iost anatomists have failed to demonstrate a trace of areolar tissue within 
the lobules of the liver. Occasionally a few fibres of a structure like fibrous 
tissue, undouhlecUy, is observed in uninjected specimens ; but such an appear- 
ance is produced by physical alterations of the structures in the lobule, in the 
preparation of the specimen, or it is the result of disease. In the lobules of the 
livers of all animals which have fallen under my notice, it loas impossible to 
demonstrate any fibrous structure ivhatever. 

" Even in the interlobular fissures of the human liver, and of others allied to 
it in structure, I have been unable to detect any fibrous structure. Bowman, 
Henle, and Vogel have altogether failed to detect any areolar tissue in this 
situation in the human liver. 

In examining such fragments, taken from the lobule of the hog, we 
often meet with rows of cells, either floating free or still adhering at one 
extremity to the fragment. In taking hold of the extremities by means of 
the needles of the dissector, and then separating them in a very slight 
degree, the row of cells will first become more straightened, and afterwards 
one or two of them usually become elongated ; if the needles are still more 
separated (but in the slightest possible degree), the separation of those two 
cells may be observed, and one or two tubular elements will appear between 
them. In PI. II. Figs. 10 and 11, this appearance is represented. These 
tubular elements I believe to be the biliary tubules; their diameter is x^loo 
of an inch. Little dilations are seen here and there in their course, which 
appear very distinct after the treatment with alcohol and other similar re- 
agents, which often gives them the appearance of a row of beads. The 
remnants of their branches are almost always still adhering ; very often we 
meet with the entire branches, representing meshes from which the cells have 
escaped. PI. II. Fig. 12 is an exact representation of a good specimen. They 
may be stretched to a great extent without breaking, and are very disten- 
sible, which is proved by injection. Unlike the fibrils of connective tissue, 
these elements do not swell up when treated with acetic acid; furthermore, 
their contours are not sharp and distinct like those of connective tissue, but 
are softer and often irregular. 

It has already been mentioned that the existence of connective tissue in 
the lobule of the liver, has been denied by most anatomists. If then these 
opinions be correct, the question, what are these elements'^ remains open 
for discussion. The only answer I can give is, that they are the biliary 
tubules, which I injected not merely in a few but in numerous livers. 

In the liver of the ox I have, in some instances, by means of the dis- 
sector, isolated one of the smaller branches of the duct, ^^^^^ 
diameter, with the remnants of biliary tubules still adhering. 

PI. II. Fig. 13 represents a dissection of a fragment of the liver of the 
hog, made with the Microscopic Dissector. The outlines of this drawing 
are accurately copied from the dissection, but for the sake of distinctness 

' Beale on the Anatomy of the Liver, p. 19. 



28 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

I have altered the shading. As the constituents of the tissue are trans- 
parent to some extent, some of the capillaries lying either above or below, 
some cells are only distinctly demonstrated by observing closely the changes 
of their position, produced by the movements of the needles; the better to 
distinguish them they are left light. This manosuvre is one of the greatest 
advantages derived from the Microscopic Dissector. 

But it is not only by injection or by means of dissection that the biliary 
tubules can be demonstrated. They can also be seen without any previous 
preparation with a high power. If a fragment from the interior of the 
lobules of the liver of the hog be taken, and after having been treated with 
ether (to get rid of the oil), it is examined with compression, a network of 
light streaks is seen, which does not correspond with the outlines of the 
cells, as might be supposed; this is the network of the biliary tubules; 
the capillaries with their nuclei can also be recognized in such a prepara- 
tion. Even in fragments, consisting only of 4-8 cells, the tubules can be 
seen. 

In taking a fragment (which has been treated with ether and then com- 
pressed) and tearing it slightly without separating it, we often observe in 
the fissures, produced by the separation, the tubules running from one 
margin to the other; after they have once been demonstrated satisfactorily, 
they can be recognized under almost any circumstances. 

ExpLAjfATioN OF THE Plates. — Plate I. Fig. 1. A tliin section of a portion of a 
hepatic lobule of tlie sheep, a. Transverse section of a branch of the portal 
vein ; two smaller branches are given off, which terminate in the capillary 
system, b. Transverse section of a branch of the hepatic duct; its finest 
branches are seen terminating in the network of biliary tubules. The fibrils 
of the capsule of Glisson are seen between the vessels ; the interspaces of the 
capillaries are filled up by the cells. Magnified 172 diameters. 

Fig. 2. A portion of a hepatic lobule of the hog. a, a. Transverse section of 
branches of the portal vein, sending off their branches to ramify around the 
lobule ; they are enveloped by the capsule of Glisson. Shorter and smaller 
branches are seen to penetrate the capsule, terminating in the capillary net- 
work, b, b. Transverse section of branches of the duct, which are distributed 
in the same manner as those of the portal vein, terminating in a capillary 
system of their own. c. Transverse section of an intralobular vein (branch 
of the hepatic vein), d. Hepatic artery, e. Fibrils of the tissue of the cap- 
sule. The cells are seen in the interspaces of the capillaries. Magnified 172 
diameters. 

Fig. 3. A thin section of the hepatic lobule of the hog, in which the duct alone is 
injected, a. Branch of the hepatic duct, terminating in the network of biliary 
tubules, b. Fibrous tissue of the capsule. The cells are seen in the inter- 
spaces. Magnified 92 diameters. 

Fig. 4. A thin section of the hepatic lobule of the hog, treated with a weak solu- 
tion of potassa. a, a, a. Capillaries, b, b. Remnants of the uninjected biliary 
tubules. The dark places are caused by the colouring matter in the vessels. 
Magnified 400 diameters. 



PLATE I. 



Ain. Jour. Med. Sciences, vol. xxxvii. 




Jour. Med. Sciences, vol. xxxvii. 



PLATE 




Fig. 12. 



Fig. 13. 



1859.] 



Schmidt, Minute Structure of Hepatic Lobules. 



29 



Fig. 5. Two cells from tke section of 

Fig. 6, which represents the outlines of the capillaries in a section treated with 

potassa. Magnified 266 diameters. 
Plate II. Fig. 7. Diagram of an imaginary section of injected liver, as it would 

look in case of the cells laying in tubes of basement membrane. 
Fig. 8. Diagram of a moderate extravasation. 
Fig. 9. Diagram of a complete extravasation. 

Figs. 10 and 11. Liver-cells at the moment of separation, showing the biliary tubules 

■ between them. 10. Magnified 266 diameters. 11. Magnified 400 diameters. 
Fig. 12. a. Biliary tubule, with branches still adhering. 6. Capillaries, c. Cells. 

d. Point of a needle of the Microscopic Dissector. Magnified 400 diameters. 
Fig. 13. Dissection made with the Microscopic Dissector, a. Biliary tubules. 6. 

Capillaries, c. Cells, d. Points of the needles. For the sake of distinction 

the capillaries are left light. Magnified 400 diameters. 

The Microscopic Needle Holder. — About eighteen months ago, when 
engaged in microscopical researches on the construction of the primitive 
nerve-fibre, I contrived an instrument which, by serving me as a support 
for my dissecting needles, enabled me to separate and stretch tissues under 
the microscope, while, at the same time, my observations with a compara- 
tively high power would be continued. This instrument answered an ex- 
cellent purpose, by enabling me to put single nerve-fibres on the stretch, but 
was insufficient for the slow and accurate movement required in some his- 
tological investigations. To accomplish this latter I was led to contrive a 
more complicated instrument, of which I shall speak hereafter. As the 
construction of the former is very simple, and is thus brought within the 
reach of every one, engaged in histological studies, I consider it worthy 
of description. 

Figs. 14 and 15 are representations of it, with a slight modification. 

It consists of three parts, viz., a needle (a) with a handle made of light 
material; a lever (b, c, d), movable in different directions, to hold the 
needle, and a brass plate (e) in which the lever turns like a pivot; tlie 
latter also supports the glass slide (/) upon which the preparation is to 
be placed. 

A portion of the needle (Fig. 14, a) is cylindrical in order to move very 



Fig. 14. 




smoothly and evenly in the lever (6); the forward, backward, and rotary 
movements being thus effected. The needle part should of course be very 
fine at its points, and slightly bent, to facilitate dissection. The lever 
No. LXXIIL— Jan. 1859. 3 



30 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

consists also of two parts. The upper (b) acts like a spring, to hold the 
needle moderately tight in its place, though loose enough to allow the 
rotary and sliding motions of the cylinder to be effected with ease. In 
the lower half of this part a round orifice (Fig. 15, h), for the reception 
of the cylinder of the needle, is seen; this orifice is 
Fig- 15. open above and below; the upper part being wider 




than below, so as to preserve the curved point of the 
needle from injury in passing through. The lower 
[C part of the lever serves as a pivot in performing the 



iLL^ rotary motion in the brass plate (e). Both parts con- 
nected form a hinge-joint (c), by means of which the 
elevation and depression of the point of the needle is effected. Connected 
with one side of the lower part of the lever is a little feeble spring (Fig. 
14:, d), which, by pressing the handle of the needle upward, keeps the point 
constantly upon the glass to maintain its hold on the tissue to be dis- 
sected, thus allowing the operator to remove his hands from the instrument 
without disturbing the preparation. This spring should not be strong 
enough to injure the delicate point of the needle. The preparation may 
be held down to the glass by a lever with spring like that of the Micro- 
scopic Dissector. (Figs. 16 and 19, b.) 

It appears from the works on the microscope and its accessory instru- 
ments, among which we may mention those of Quekett and Carpenter, that 
microscopic dissections had been previously carried on by means of fine 
needles attached to a handle, and managed only by the hand. The dissec- 
tions made in this manner could only be performed under a very low power, 
and would necessarily be very coarse ; for the slightest movement of the 
hand, scarcely observable by the unaided eye, would (under a high micro- 
scopic power) make the needle sweep almost over the whole field. 

In former investigations it had been customary to separate the tissues 
finely before examination. But this is only blind dissection, since we are 
unable by this process to observe the changes going on during separation 
and destruction, and only observe their appearance after the minute struc- 
tures have been partially destroyed. 

To obviate these difficulties, and to carry on my microscopic observa- 
tions with more accuracy, I contrived an instrument, which I have now 
in use, and shall now describe. 

The Microscopic Dissector. — In the construction of this instrument, the 
principal object I had in view was, to be enabled to make the slightest 
motion of microscopic needles, knives, or scissors, in different directions. 
This can only be accomplished by the screw movement, which also keeps 
the instruments stationary, and thus gives freedom to the hands for chang- 
ing object glasses or eye pieces, or applying reagents, while the preparation 
is undisturbed. 

The instrument consists of three levers (A, A, A) to hold the needles, 



1859.] 



Schmidt, Minute Structure of Hepatic Lobules. 



31 



one lever (B) with spring to fix the preparation to the glass, a brass ring 
(C) with a shoulder for the glass (D) to rest upon, and two cog-wheels 
to rotate it. These several pieces are connected with a brass plate (F), 
upon which they move, and the form and size of which will vary, according 
to the stage of any particular microscope. 

In order to simplify the description of this complicated instrument, I 
shall speak of these different pieces separately. 

The lever (A, Figs. 16 and 11) is destined to hold the instruments, and, 



Fig. 16. 




therefore, must have motion in all directions. Like the Microscopic I^Teedle 
Holder, it consists of two principal parts (Fig. It, a, h), which together 
form a joint by which the upward and downward motion is effected; the 
lower one (6) rotates in the brass plate {F) by which the horizontal move- 
ment is accomplished. The longer extremity of the upper part (a) is bent in 
a right angle, and has a round hole in which a nut (Figs. 16, It, and 18, c) 
moves. To keep this nut in its place, it has a small notch, which by means 
of a pin secures the former and prevents it working out. The shorter extre- 
mity, or body part (Fig. IT, a), has a square hole, in which the piece (Fig. 



32 



Schmidt, Minute Structure of Hepatic Lobules. 



[Jan. 



It, d), to wliich the different instruments are screwed, moves forward and 
backward. One extremity of this piece (d) is square, to prevent it from turn- 



Fig. 17. 




ing, and must work very nicely in the square hole of the lever, for the accu- 
rate movements of the point of the needle depend to a great extent upon the 

Fig. 18. 




precision of this sliding motion. The other extremity has a fine thread cut 
on 8.nd passes through the nut (c), and thus the screw-movement for effect- 
ing the advance or retreat of the instrument is established. To produce 
the up and down movements of the lever, we have another piece (Figs. IT 
and 18, e) added, which has a joint at its lower part; the upper part has a 
thread cut on, which forms a screw-movement with the nut (Figs. 16, IT, 
and 18,/). This nut has a notch on one end, in which a lateral pro- 
longation of the lever (a) slides (Figs. 16 and IT, a,f, and Fig. 18, e, a,f, 
show this plainly). It will be seen that the nut (/) being held to the 
lateral prolongation of the lever (a) by means of the notch, will produce 
the upward and downward movements of the instrument, when turned on 
the screw of the piece (e), as the latter is attached to the brass plate. A 
third piece is added to effect a sideward movement; this is best seen 
in Fig. 18, where it is marked by the letter g. The lower part of this 
piece rotates in the brass plate (F) ; the upper one is split like a fork, in 
which the nut (A) turns and slides freely up and down, according to the 
upward and downward motion of the lever with which it is connected by 
the piece (i). The one extremity of the latter (i) is connected by a pin 
with the longer extremity of the lever (a), and thus forms a hinge-joint, 
while the rest (k) has a thread cut on, with which the nut (h) forms a 
screw-movement. If we now look at the lever (A) in Fig. 16, we can 
readily perceive how, by turning the nut {h) in one or the other direction, 



1859.] 



Schmidt, Minute Structure of Hepatic Lobules. 



33 



the distance between the longer extremity (a) of the lever is either in- 
creased or diminished, and consequently the point of the needle moved 
toward one or the other side. 

The lever (B) for holding the preparation is represented in Figs. 16 and 
19. It consists of two parts; the lower one (a) rotates in the brass plate 
(#); the upper one forms the true 

lever; it has an oblong opening in Fig. 19- 

the middle, which slides along a screw n 



connected to the former, serving as a v . ^-^ ^g^ 



a spring, and is intended to hold the 6±: \ 

preparation to the glass, the other 

has a spring attached to it. By this arrangement the point of the lever 
can reach the preparation at any place of the glass. 

The brass ring (G) has a shoulder for the glass to rest on; its circum- 
ference has teeth to form a cog-wheel, and to be thus revolved by the two 
other cog-wheels (E, E). 

The glass (D) is a simple round glass plate, which rests on the shoulder 
of the brass ring (0). The glass plate fits also to a similar ring of my 
compressor ; so that a preparation previously dissected may be compressed 
without disturbance, by simply transferring the glass slide on which it 
rests. 

The cog-wheels {E, E) are simply held down to the brass plate {F) by 
screws with a large head, the one has two buttons (Fig. 16, a, a) to 
turn it. 

The hrass plate (F) has been mentioned already; it may be attached 
to the stage by means of small clamps. 

Besides the dissecting needles, microscopic scissors, forceps, and knives 
(Figs. 20, 21, and 23), may also be worked by the instrument. The needle. 



(Fig. IT, I) can be unscrewed, and other instruments substituted, as is seen 
in Fig. 20. The scissors (Fig. 20, m) are opened and closed by turning 
the nut (n), the notch of which is embraced and slides on the fork -like 
handle of the former (Figs. 20 and 22). The forceps are managed in the 



fulcrum. One extremity is thin like 




Fig. 20. 



Fig. 21. 



Fig. 22. Fig. 23. 




34 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

same manner. Fig. 28 is a small knife for scraping off epithelium from 
small ducts, &c., after they have been cut open with the scissors. 

The accompanying figures give so accurate a representation of this in- 
strument, as to supply any deficiencies in my description. I have, however, 
to say that the threads of the screws are not represented as sufficiently close 
in Fig. 16. To Mr. Gemrig, No. 109 South 8th Street, I am indebted for 
the accurate construction of the instrument from my drawings, and I can 
cordially recommend him as one capable of executing any work of the kind. 
I am also under obligation to his workman, Mr. Wolf, the maker of the 
instrument, whom I consider the most accurate workman in his line I have 
yet met with in this country. 

I cannot speak too highly of the instrument, for without its assistance, 
it would have been impossible for me to examine the microscopic structure 
of the liver so successfully. Yet it is, of course, susceptible of improve- 
ment, and by none more likely than my old friend Mr. Liier, of Paris, 
whose well established reputation has no need of my indorsement. 

The management of the instrument requires a little practice, as the 
object is reversed in most microscopes. In turning the nut by which the 
point of the needle is brought toward the glass, much care should be 
taken to preserve the point from injury, by pressure against the glass. 
No part of the instrument should be unsteady, while at the same time the 
motions should be easily effected, that the hand may detect the moment 
the needle-point touches the glass. The whole success of the manipulation 
depends on the accuracy of these movements. The point of the needle 
must be very fine ; this is best accomplished on an Arkansas hone, and 
by the aid of a magnifying-glass of a low power. Sometimes, even 
with the greatest care and precaution, the point will break. To be obliged 
to apply to an instrument-maker to adjust it each time, would occasion 
much inconvenience. The investigator himself may obviate this difficulty, 
by annealing the needle first in the flame of a spirit-lamp, and afterwards 
bending the point, and then hardening and tempering it again. There is 
an inconvenience connected with the instrument, which, though slight, com- 
pared with its advantages, is scarcely noticeable, viz., when the point of the 
needle enters the liquid in which the tissues are dissected, the motion pro- 
duced disturbs the rays of light, and confuses the appearance of the object; 
but this lasts only until the point of the needle has fairly entered the liquid 
and touched the tissue, when all will be as clear as before. The best liquid, 
therefore, to keep the tissues moist, will be one of a low specific gravity, 
which will allow the point of the needle to enter, without itself being too 
much disturbed. Water answers this purpose better than alcohol or tur- 
pentine, which evaporate too quickly. Glycerine, which is an excellent 
medium for the examination of tissues in other cases, is of too high a spe- 
cific gravity for this purpose. The tissue should not have more liquid above 
it than is necessary for moisture, to prevent disturbance of the rays of light. 



1859.] Schmidt, Minute Structure of Hepatic Lobules. 35 

In using the No. 3 object-glass of my microscope (whicb is one of Nachet's), 
after tlie tissue is dissected, and properly adjusted for a favourable observa- 
tion, it has been my custom to fill up the interspace between the tissue and 
the lens with water, or diluted alcohol, thus preventing any disturbance of 
the rays of light in passing through it, and also affording am pie time before 
the evaporation of the liquid, for making any drawing. 

The advantages and disadvantages incident to this, might be enlarged 
upon, but the operator's judgment and mechanical skill will readily suggest 
remedies for its defects ; to its advantages, I can give my testimony, 
having used it without any difficulty. To manage the instrument suc- 
cessfully, delicacy of touch and a great deal of patience are required ; but it 
is only by the latter, combined with perseverance, energy, and close obser- 
vations, that scientific facts have, or ever will be, established. 

Apparatus for making Microscopic Sections of Tissue. — This appa- 
ratus, by means of which I have made hundreds of the finest microscopic sec- 
tions of various tissues and organs, is of even greater utility than the "Dis- 
sector." I designed it with the object of obtaining fine sections of the spinal 
marrow, or brain-matter, to aid in my researches on the nerve-structures. 
It seems worthy of remark, that at that time, in my references to the writ- 
ings of several eminent investigators, I found the razor (which they con- 
sidered the sharpest instrument), the only one regarded as most suitable for 
this purpose. This erroneous idea is readily accounted for; the razor hav- 
ing a very thick back, is more readily brought to a fine edge than any other 
knife. The reason is obvious ; in honing a knife, the object is to remove 
the rough wire edge produced by the grindstone and polishing-wheel, and 
give to the blade another, smoother, and infinitely finer. Now, to do this, 
the nearer level we can render the two sides of the knife, the finer the edge. 
Or, in other words, the blade of the knife must form the same angle with 
the surface of the hone at each stroke, or the edge becomes round, and con- 
sequently dull. In honing the razor, less difficulty is experienced. The 
thick back will form an angle of the proper degree, when it rests on the 
surface of the hone, while, with another knife, much practice is necessary 
to preserve the same angle at each stroke. But the advantage of a 
keen edge which we obtain by using the razor, is counterbalanced by the 
clumsiness and thickness of the instrument in penetrating between the very 
fine slice of tissue, and the piece from which it is cut. Now, to avoid 
all these disadvantages, I have my knife, which is thin, arranged in such a 
manner as to enable every one to hone it with great facility ; but I shall 
speak of this hereafter. Valentine's knife seemed to me useless for deli- 
cate, soft structures ; it may do well enough for cartilaginous tissue ; but 
even then, if the edge of one blade is not as keen as that of the other, 
it can never make a good section. As I have never used the knife, how- 
ever, I can express no positive opinion about it. 



36 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 

In fact, it is almost impossible to make fine and uniform microscopic sec- 
tions of the spinal marrow, of any considerable size, unless the knife be 
guided, by sliding over some smooth surface. 

To accomplish this object, I at first cut a hole the exact shape of a trans- 
yerse section of spinal marrow, in a small piece of thin board. Putting 
a piece of the former (previously hardened), through this hole, so as to 
project a little above the surface, I could slide a sharp scalpel over the sur- 
face, and cut fine sections comparatively easily. But there was still some 
trouble by the adhesion of the slice to the knife, which was remedied by 
cutting under water. 

The principal portion of this apparatus (Fig. 24) consists of one plate 
upon which the pieces, destined to guide the knife blade move ; a second 



Fig. 24. 




plate destined to hold the tissue to be cut ; and a third one, in which the 
screw that regulates the thickness of the slices moves. 

The plate (Figs. 24, 25, and 26, a) or stage of the instrument is round, 



1859.] Schmidt, Minute Structure of Hepatic Lobules. 3t 

has a round orifice in the centre, and four others between the centre and 
the periphery. In each of these peripheral orifices a piece (Fig. 26, b) is 
made to slide forward or backward, by means of a screw (Figs. 24, 25, and 
26, c) which turns in the plate (a). To the piece (b) can be attached 
smaller plates (d and e), which are intended to press against the sides 
of the spinal marrow, or other tissues, to hold them when cut ; the surface 
of these plates (d and e) serves to ^uide the knife blade ; by referring to the 
drawing, it will be noticed how they are attached to the pieces (b) by 
screws; it will also be observed how these plates <jan either be made to 



Fig. 25. 




advance or recede by turning the screws (c). By this movement the pre- 
paration is held or loosened. The plates (d) in Fig. 25, as can be seen by 
their shape, are suited to hold a piece of spinal marrow; those in Fig. 26 
(e) have their inner margins parallel to hold other tissues, as liver, kidney, 
&c. The plate (/), by means of four cylinders, is attached to the plate 
(a); these cylinders (h) assist in the accurate sliding movement of another 
plate (g) upon which the preparation rests ; three sharp points can be seen 
upon this plate to prevent the preparation from moving sideways. A 



38 Schmidt, Minute Structure of Hepatic Lobules. [Jan. 




{g), upon which the preparation rests, either upward or downward, and 
thus the thickness of the sections to be cut is regulated. The instrument 
should be made of brass. 

As the cutting under water is one of the principal points in making good 
sections, I have a box of sheet tin, about one foot square, which is filled 
with water, and in which the instrument rests horizontally upon brass sup- 
ports soldered to the bottom of the box. 

As the spinal marrow varies in shape and thickness at different places 
in its course, there should be different sets of plates adapted to each por- 
tion. Eor the spinal marrow of small animals, two plates like Fig. 2*7 
will be sufficient. 

This instrument has been made to my satisfaction by Mr. 0. Mannel, 
No. 104 Arch Street. 

To make fine sections of nerves, an arrangement like Fig. 28 will an- 



1859.] 



Schmidt, Minute Structure of Hepatic Lobules. 



39 



swer, which is a flat piece of wood, -/^ of an inch thick, with a little 
spring on each side to hold the extremities of the nerve. In making fine 



Fig. 27. 



Fig. 28. 





Fig. 30. 



Fig. 31, 



sections of liver, kidney, &c., or longitudinal sections of 
spinal marrow, I cut the piece, which shall furnish the 
sections, rectangular, and put it upon a piece of cork, pro- 
vided with two little points, as is seen in Figs. 29 and 30. 

The knife (Fig. 31) should be thin and very sharp, and 
slightly bent on one side, to prevent interference with the 
screw buttons ; its back {a) is arranged to be slipped on, 
for the. process of honing, and off when used for cutting. 
The cutting should be done from below upward, and by a 
scarcely perceptible sawing motion ; if the knife is drawn 
only in one direction, the section will tear. If the section 
is well made, it ought to be thin enough to read fine print 
through it. In cutting spinal marrow, where four plates 
{d) to guide the knife and hold the preparation are re- 
quired, care must be taken not to touch the angles of the 
plates with the edge of the knife in passing ; for this pur- 
pose, those angles should be rounded off a little. After 
the section is cut and floating on the water, it is then caught 
fairly on a spatula, while yet under water. It is scarcely 
necessary .to give more particulars in regard to the use of the instru 
ments, the operator will soon discover them. 



40 



Levick, Remarks on Sunstroke. 



[Jan. 



The Mounting Forceps (Figs. 32 and 33) was inyented by me for hold- 
ing the covering glass to the glass slide, when wiping and cementing its 
edges. It consists of a small forceps, to the jaws of which four little 



Fig. 32. Fig. 33. 




springs are attached, forming a movable joint; thus the distance between 
the extremities of the springs can be regulated, according to the size of the 
covering glass ; the forceps is kept shut by a spring between its handles. 
This instrument will be found very useful for mounting microscopic prepa- 
rations. 



Art. II. — Remarks on Sunstroke. By James J. Levick, M. J)., 
of Philadelphia. 

Until a comparatively recent period there had been but little written on 
the subject of sunstroke, the name popularly given to those sudden attacks 
of loss of consciousness, with laboured respiration and prostration, which 
occur in such numbers during the summer season. 



1869.] 



Levick, Remarks on Sunstroke. 



41 



This circumstance may be attributed to two distinct causes : first, that, 
though of frequent occurrence with us, sunstroke is rare in England. It 
was from the mother country that, until comparatively lately, we derived 
most of our medical literature, and, as intimated, in England the affection 
is almost unknown. Dr. Watson, in a brief allusion to the subject, states 
that he has never seen a case of the kind ; and many English writers seem 
to ignore the existence of such an affection, by omitting any allusion to it 
in their treatises on the practice of medicine. What is known, of it by our 
brethren in Great Britain appears to have been learned from the experience 
of the surgeons in India, where its effects are so fearfully felt. A second 
cause may be found in a mistaken classification, many cases of what would 
seem to have been genuine cases of sunstroke having been erroneously re- 
garded as apoplexy, acute congestion, and inflammation of the brain. 

And yet sunstroke has had its victims from the earliest times. In the 
sacred volume we have two instances recorded. The first, that of the son of 
the Shunammite, who, being "in the field with the reapers, said unto his 
father, 'My head, my head!' And when he had taken him to his mother, 
he sat on her knees till noon, and then died." (2 Kings iv. 19.) And 
again in the text given by Dr. Watson : 'And Manasses was her husband, 
of her tribe and kindred, who died in the barley harvest; for as he stood in 
the field, overseeing them, and bound sheaves, the sun came upon his head, 
and he died in his bed in the city of Bethulia." 

In looking over the various numbers of the American Journal of 
the Medical Sciences, from its commencement to the present time, I find 
twenty-four volumes to have been issued without a single paper on this 
subject, or even an incidental reference to the disease, as such. The first 
allusion to it is a short paragraph above the initials of "T. R. B.," 
which appeared in vol. i., S., p. 536, published in 1841, and which is as 
follows: 'At this season, in 1821, the British frigate Liverpool was pro- 
ceeding from Muscat to Bushire ; the weather gradually increased in warmth ; 
double awnings were spread, the decks kept constantly wetted, and every 
precaution used to prevent exposure of her men; yet in one day, from a 
species of coup de soleil, she lost three lieutenants and thirty men. If, for 
however brief a period, they exposed themselves to the sun, they were 
struck down senseless; vertigo followed, accompanied by foaming at the 
mouth." It is added: "The frigate's deck at one time resembled a slaugh- 
terhouse, so numerous were the bleeding patients." ( Wellsted^s Travels to 
the City of the Caliphs.) It will be remembered that the Persian Gulf 
intervenes between Bushire and Muscat, the latitude being about 25°. 

In the same journal — vol. xviii., N. S., p. 66, 1849 — Dr. H. Hartshorne 
reports four cases as treated at the Pennsylvania Hospital, two of which 
died. 

In vol. xxi. p. 183, quoted from the Transactions of the College of 
Physicians, is a highly interesting paper by Dr. Pepper on the subject, in 



42 



Levick, Kemarks on Sunstroke. 



[Jan. 



which it is stated that ''during the seven years preceding, twenty patients 
had been treated in the Pennsylvania Hospital for sunstroke; of these, ten 
died, seven recovered, and three became affected with a chronic affection of 
the brain, eventuating in insanity." Added to the paper of Dr. Pepper are 
some valuable remarks by Dr. Condie on the same subject. In the same 
volume, page 536, is an able article by Dr. Lente, then Resident Surgeon 
at the New York Hospital. In this it is stated that in the year 184*7 there 
were thirty-seven cases of sunstroke occurring in the city of New York in 
four days, most of whom died so promptly that it was impossible to con- 
vey them to the hospital. Of forty-two admitted into the hospital dur- 
ing five years, twenty-four died and eighteen survived. In the "Transac- 
tions of the Boston Society for Medical Improvement" — reported in vol. 
xxvii., 1854 — several cases are recorded: and in the last published num- 
ber of the Journal some brief remarks are offered on the same subject by 
the writer of this paper. 

In the Philadelphia Medical Examiner, vol. i., N. S., p. 526, Dr. 
DowLER, of New Orleans, in the course of some experimental observations 
on animal temperature, incidentally alludes to the subject of insolation. 
After expressing his surprise that so little distinction is made between 
solar asphyxia, as he calls it, and solar syncope, he says "solar asphyxia 
is always fatal;" but adds that this might be curable if the patient were 
bled instantaneously. He states that on the 23d of July, 1845 — the ther- 
mometer being 105° to 150° in the sun — fifteen victims perished in one day 
in the city of New Orleans from sunstroke. 

Essays on this subject have at various times appeared in the New York 
journals. One of the most comprehensive of these is that of Dr. Dowler, 
published in the New York Medical Gazette, July, 1851, and republished 
in the New Orleans Medical and Surgical Journal, January, 1856, page 
410. Dr. Israel Moses records some interesting cases in the New York 
Medical and Surgical Reporter for the year 1846. 

One of the most instructive and complete essays which have come under 
my notice in our recent journals is that of Dr. H. H. Swift, then Resident 
Physician of the New York Hospital, and published in the New York 
Journal of Medicine, vol. xiii., N. S., p. 45, 1854. I shall have occa- 
sion frequently to allude to this paper, and cannot avoid here stating that 
it enters so fully into the subject, that the results of the observations made 
by the author, and the inferences thus drawn and expressed, correspond so 
closely with my own, as to leave but little unsaid that I could wish to say. 
After describing the three different stages of the affection, as he considers 
them. Dr. S. states that of one hundred and fifty cases admitted to the 
New York Hospital, seventy-eight died. 

In the Buffalo Medical Journal for 1856 is a paper by Dr. S. B. Hunt 
on sunstroke, having especial reference to its exciting causes. Allusions 
to the subject may be found in the writings of Drs. Wood, Gerhard, Dick- 



1859.] 



Levick, Remarks on Sunstroke. 



43 



SON, Cartwright, and others of our own countrymen. As I have already 
intimated, but little has been written on this subject by the English. 
MosELY, in a treatise on tropical diseases, published in London A. D. 1803, 
page 57, says: "In England, in ItOT, on the 8th of July, many people at 
work, and many horses and oxen, were killed by the sun's rays; and in Pe- 
kin, in the year 1*743, between the 14th and 25th of July, eleven thousand 
people perished in the streets from the same cause!" In the Medical Ga- 
zette, vol. xviii. p. Yl, is a paper by Mr. Russel, of the 1M regiment, 
then stationed at Madras, which, so far as I am aware, is the first which 
gives the true pathological condition found after death from sunstroke. 
The Medical Times and Gazette, 185 1, page 416, contains in a paper on 
the diseases of the brain and nervous system, as they affect soldiers, &c,, in 
India, by Charles Alexander Gordon, surgeon to the 10th regiment, in 
which is given a brief notice of sunstroke as it occurs in India. Out of 
twenty-eight cases coming under this writer's notice, but one recovered. 
The latest — and, so far as I know, the best trans-Atlantic publication ap- 
peared a few months since in vol. xv., N. S., p. 624, of the same journal, the 
author of which, Dr. Beatson, a surgeon ^in the army of India, employs 
Dr. Gordon's paper just referred to as a text for his subject, rejecting alto- 
gether the pathological and therapeutical views of Dr. Gordon. 

As respects the frequency and fearful character of this affection, the pre- 
ceding notices are of themselves sufficient evidence. Thirty-seven cases of 
sunstroke in four days, almost immediately fatal, as reported by Dr. Lente, 
fifteen deaths from this cause in one day, as recorded by Dr. Dowler, cer- 
tainly present the matter in a sufficiently serious light, without further 
facts on my part ; and yet the scenes I have myself witnessed, though 
never so fearfully numerous as those above recorded, have impressed me 
even more forcibly than this frightful catalogue alone could have done. In 
most other diseases the victim has some forewarning of his doom. When 
pestilence stalks the streets, men are on the fearful watch for its approach, 
and are prepared, at least for a time, to combat the destroyer; if they fall, 
it is with a broken sword, and with their armor pierced. But sunstroke 
gives no such warning. It strikes down its victim with his full armor on. 
Youth, health, and strength oppose^o obstacle to its power; nay, it would 
seem, in some instances, to seek out such as these, as if boldly to flaunt its 
power, and in the very glare of day to deal its fatal blow. Those who have 
witnessed the scenes of domestic distress which every summer affords us, as 
husbands and fathers, who, but a few hours before, had left their families 
in full health, are brought back to them struck down by death, will not 
think me disposed unnecessarily to deepen the picture. As I have elsewhere 
said, I know no place other than the field of battle where such sudden de- 
struction of human life occurs. 

The symptoms of sunstroke are now too well known with us, at least, 
to render a detailed description of them necessary. Dr. Beatson gives 



44 



Levick, Remarks on Sunstroke. 



[Jan. 



three symptoms as the prominent ones in his cases, viz. : unconsciousness, 
laboured respiration, and extreme prostration ; these are unquestionably 
the conditions we meet with in sunstroke ; but similar phenomena present 
themselves in other affections. When, however, an individual, and still 
more so when a number of persons in ordinary health exposed to a tem- 
perature approaching 90° F. in the shade, are suddenly seized with these 
symptoms, for a moment perhaps preceded by thirst, vertigo, and a con- 
fused perception of colours, there can be little doubt that the attack is that 
of sunstroke. 

The appearances described by different writers are very dissimilar. By 
some the pupil is found contracted, as in one case described by Russel (loc. 
cit.) ] so, too, by Hartshorne ; while, on the other hand, Drs. Pepper, 
Lente, and Swift (loc. cit.), speak of dilatation of the pupil as of most 
frequent occurrence. Dr. Swift, however, adds that in what he calls the 
third stage, the pupils are often firmly contracted. "Of 33 fatal cases, the 
pupils were contracted in 20, moderately dilated in 7, and markedly so in 
6 ; in the successful ones the pupils were dilated m 19, nearly natural in 
15." (Swift, loc. cit.) This corresponds with what I have myself noticed. 
The probability is that the condition of the iris varies with different de- 
grees of the affection, and is by no means a pathognomonic feature of the 
case. 

The pulse, too, is differently described ; by some as full and slow, by 
others as frequent, feeble, and thready ; by Dr. Strong, of Boston, as in 
some cases ''very strong;" by Dr. Coale, of the same society, as ''very 
small." Dr. Dowler says : "The pulse is hurried, hobbling, and unequal, 
very often gaseous or air-like, but never slow, hard, and large, as in apo- 
plexy." I have always found the pulse a feeble one; it is true, in some in- 
stances, a full one, but easily compressed, and frequent. 

Coma and stertor are recorded by some as of almost constant occurrence, 
by others they are not mentioned. I have seen in some instances violent 
convulsions, while in the greater number of cases they have been absent. 
The truth is, as I have already intimated, that the symptoms vary with the 
difference in the intensity of the affection, and though it has not occurred 
to me to notice in so decided a manner the three stages described by Dr. 
Swift, yet I am quite prepared to adopt his classification. Dr. Dowler 
{loc. cit.) makes "a particular arrangement or classification of solar dis- 
eases, which is highly important in a practical point of view." He "sub- 
mits the following: 1st. Solar Exhaustion or Syncope. 2d. Solar or Sun- 
pain. 3d. Solar Excitement or Inflammation. 4th. Solar Asphyxia." 

" Solar exhaustion," he says, "differs from solar asphyxia both in symp- 
toms and treatment. In solar asphyxia, the skin is extremely hot and 
generally dry ; there is a choking sensation, and a total loss of sense. In 
solar exhaustion, the skin is moist, pale, and cool ; the breathing is easy, 
though hurried; the pulse is small and soft; the vital forces fall into a 



1859.] 



Levick, Kemarks on Sunstroke. 



45 



temporary collapse, the senses remaining entire. Horizontal position, free 
air in the shade, external stimulants and frictions, are usually sufficient to 
restore the patient." The extensive experience of Dr. Dowler and his 
well known habits of accurate observation, give great weight to whatever 
suggestion he may make on this or any other subject ; but, though cer- 
tainly existing to some extent, I must acknowledge that the distinction 
between the different forms of solar disease has not been so well defined in 
the cases coming under my notice as in those seen by him. 

The cause of this affection is suggested by the name popularly adopted, 
and though by no means of scientific origin, the term sunstroke or heat- 
stroke, so long as we remain uncertain as to the exact pathological condi- 
tion, may as well be retained. 

While exposure to the direct heat of the sun is by far the most frequent 
cause of the affection, it is by no means the only one. Dr. Swift mentions 
eleven cases as occurring in a laundry, and several others in a sugar 
refinery ; and the first case seen by me during the past summer was that of 
a man who had been at work for ten hours in a sugar refinery. 

What is the kind of heat, and under what circumstances is it that these 
disastrous effects are produced ? Almost all writers agree in classing 
among the causes which predispose to this result, fatigue, intemperance, 
improper clothing, being clad, as Dr. Dowler expresses it, ''in garments 
which afford but a feeble resistance to the conduction of heat into the body." 
Dr. Beatson (loc. cit.) states that "it seldom occurs except after fatigue 
and exhaustion, under a tropical sun, aggravated, no doubt, by whatever 
tends to obstruct the freedom of the venous circulation of head and neck, 
and to produce such obstruction, I know of nothing — short of hanging — 
more effectual than the old leather stock and tight coatee collar." He 
might have added, anything which compresses the chest or waist, and thus 
interferes with the free expansion of the lungs, A case of this kind occur- 
red in front of my office, on the occasion of the military parade in celebra- 
tion of the laying of the Atlantic Telegraph Cable. A robust German 
soldier fell over in a state of unconsciousness, with laboured respiration, 
followed by a slight convulsion. I found him with a cravat fitting almost 
to strangulation, and with a belt so tightly encompassing the waist as to 
completely prevent the free and healthful expansion of the thorax and its 
contents ; nor was it until all these ligatures had been removed that the 
favourable symptoms which terminated in recovery presented themselves. 

While accepting the above as frequent auxiliaries in the development of 
sunstroke, my own observations by no means agree with those who believe 
it occurs chiefly to such as are addicted to the intemperate use of intoxicat- 
ing drinks. Such was not the case with the patients treated in our hos- 
pital last summer, nor with those reported by Dr. Swift. In India it 
attacks most frequently soldiers whose military duties prevent such indul- 
gence. So too with the sailors before reported. It is true, that scarcely 
No. LXXIIL— Jan. 1859. 4 



46 



Levick, Remarks on Sunstroke. 



[Jan. 



a summer passes that cases of unconsciousness from intoxication are not 
brought to the hospital as cases of sunstroke, which, at the first glance, 
might be so considered. Sunstroke is by no means confined to the intem- 
perate ; indeed, I am much inclined to believe- that a moderate amount of 
stimulant might act as a prophylactic. TJnacclimation I believe to be a 
strong predisposing cause. With one exception, all the men treated in the 
Pennsylvania Hospital during the past summer were foreigners. Position 
acts as a favouring cause ; as in stooping or bending forward. This was 
illustrated in the cases occurring among labourers employed in working 
with pickaxes in making the passenger railways in our city during the late 
summer ; in two cases related by Dr. Coale, of Boston, of sailors attacked 
while bringing a ship to anchor; as well as in the many instances of day 
labourers, most of whom are in this position while at work. 

But none of these circumstances is necessary for the production of the 
disease, and I have seen it attack with equal fatality th^ strong and vigor- 
ous as the enfeebled and poorly nourished. I have never as yet met with 
sunstroke affecting a negro, though told that such cases are not uncom- 
mon in the South ; and the natives of India are, it is well known, not 
exempt from it. 

What is the peculiar character of the heat which produces these effects ? 

Had this question been asked me before this paper was begun, I should 
have replied, from a vague impression made on my mind, that sunstroke 
was. most frequent during an intensely dry heat. Such, however, does not 
accord with the observations of others, and such, I am inclined to think, 
from a more careful investigation, is not the case. 

Dr. Sandford B. Hunt, in a paper on Sunstroke published in the Buf- 
falo Medical Journal, advances the opinion, that a high humidity of the 
atmosphere is the condition most favorable for sunstroke. He quotes, 
among other cases to sustain this view, the eleven instances related by Dr. 
Swift as occurring in a laundry, the atmosphere of which, he asserts, was 
doubtless surcharged with aqueous vapour from the dampened Imen. A 
somewhat similar condition of the atmosphere may be supposed to exist in 
a sugar refinery. In all cases coming under his notice, he found a high 
dew-point contemporaneous, and he ascribes the fatal results to the absence 
of the refrigerating effects of free evaporation from the surface. During 
three days of last summer, in which six cases of sunstroke were brought to 
the hospital, and in which many other cases occurred, the maximum tem- 
perature in the shade was 94° F, the barometer about 30, and the dew- 
point at 9 A. M. of each day was 74, 12, 12 — a high range even when we 
regard the temperature, of which the record in the shade can give but an 
imperfect conception. In the very first case quoted by me, that of Well- 
sted in the Persian Gulf, it is said that the decks were kept constantly 
wetted, which, if the above view be correct, must have increased the number 
of fatal cases. It is true, that Russell {cit. supra) reports his cases as 



1859.] 



Levick, Ecmarks on Sunstroke. 



47 



occurring "at a season when the hot land winds had just set in, rendering 
the atmosphere dry and suffocating;" but, on the other hand, Dr. Gordon, 
writing from India, says: "India officers say the heat is not so much to be 
feared during the intensity of tlie dry heat, as in those calm sultry days 
when the sun is obscured by a film of clouds, or by impalpable dust, at 
seasons diffused through the atmosphere, these being the frequent precur- 
sors of an earthquake." Dr. Beatson reports as the condition of the com- 
pany to which he was attached, that they remained for three days and tv*^o 
nights located on a dry open rice flat without tents, exposed to and utterly 
unprotected from the blazing sun by day and the heavy dews by night. 
From a remark made by Dr. Dowler {Iog. cit.), I infer that his views cor- 
respond with those of Dr. Hunt. The latter correspond, too, as I shall 
hereafter show, with the occurrence of what are described by the older writ- 
ers as predisposing causes of apoplexy. Though contrary to my own pre- 
conceived notions on the subject, I think it but fair to repeat that these 
views appear to be held by the majority of careful observers, and are well 
sustained by them. 

Before calling attention to the pathological appearances and nature of 
the disease called Sunstroke, I wish for a few moments to recur to a state- 
ment made by me in the early part of this paper, that the paucity of medi- 
cal literature on this subject, among the earlier writers, is to be accounted 
for on the supposition that many cases described as other diseases were 
really and would now be recognized as cases of sunstroke. Not to men- 
tion the cases of "death from cold water," which, I believe, are now gene- 
rally admitted to have been instances of this kind, I am quite convinced 
that many cases of insolation have been regarded and treated as cerebral 
apoplexy. 

Andral, in his Clmique Medicate, when describing various forms and 
causes of cerebral congestion, has the following : ' — 

" Three labourers occupied in three different places in getting in the harvest 
during days when Reaumur's thermometer marked 40° (122 F.) in the sun, died 
suddenly. The circumstances accompanying these three deaths could only be 
ascertained in two of them, for the third was found dead. According to eye- 
witnesses, the two former could not have left their work more than five minutes 
before their death. They turned round, putting their hands forward, as if they 
had been deprived of sight and must have expired at the moment when they 
wished merely to sit down. The individual who died first, that is, on the 6th of 
July, was a man of mature age, but putrefaction made such rapid progress that 
it was impossible to keep his body till the proper time for examining it. The 
second died on the following day. It was a woman twenty-one years of age. 
Her body was examined — muscles well-developed; all the articulations were 
completely rigid ; on the back and face were livid spots, and already the odour 
of putrefaction began to manifest itself; abdomen tympanitic, smooth, and free 
from spots. * * * No effusion was found between the dura mater and bones of 
the cranium, nor was any found over or under the pia mater, but the veins and 
arteries of these two membranes were gorged with blood. The brain presented 

' Vide Medical Clinic, or Reports of Cases by G. Andral, Professor, &c., translated 
by D. Spillan, M. D., &c. Bell's Medical Library, vol. viii. p. 199 et seq. 



48 



Levick, Kemarks on Sunstroke. 



[Jan. 



no irregularity, only its substance was very soft ; tlie ventricles contained a little 
more serum than natural ; * * * no signs of inflammation of the lungs or pleura, 
nor any effusion the pulmonary vessels were gorged with blood, and the 

bronchi filled with frothy mucus ; ^ * * size of the heart natural ; right ventricle 
a little distended and filled with liquid black blood ; the left ventricle contracted 
and empty. On opening the abdomen, an infectious odour was diffused ; * * -J^- 
the uterus and ovaries contained a little liquid blood, and in the cavity of the 
pelvis were found an effusion of two ounces of blood. The third person died 
suddenly on the 8th July. This was a stranger, a woman between forty-eight 
and fifty years old. We proceeded on the following day in the morning to exa- 
mine her body. * All the articulations were rigid ; the back was traversed 
by blue spots ; almost the entire face was covered with them ; the face from the 
chin to the nose was absolutely livid ; several were also to be seen on the chest, 
the size of which varied from that of a lentil to that of a twenty sous piece. 
These spots had precisely the appearance of petechiae, and yielded when cut into 
some liquid blood. The body was still warm, but exhaled a fetid odour ; the 
abdomen was tympanitic ; the integuments and bones of the cranium presented 
nothing extraordinary; their vessels, as well as those of the brain, contained 
some liquid blood ; the cerebral substance was extraordinarily softened ; the late- 
ral ventricles contained a bloody serum. The pericardium presented a slightly 
inflammatory tint on its inner surface ; the right ventricle of the heart contained 
a little black liquid blood ; the blood of the left ventricle was red and frothy, 
&c. &c." 

A little further on, in the same treatise, the author has the following 
paragraph : — 

"Baglivi, in 1694, and Lancisi, in 1705, saw apoplexy suddenly become so 
common in certain parts of Italy that they have described it as having been in 
those years really epidemic." 

I have looked into these old authors, and find in the former the follow- 
ing quaint and interesting statement : — 

For these last two years (I mean 1694 and 1695), the Apoplexy has swept off 
great numbers of People both in this city and all over Italy, and the fatal effects 
of this Disease were so frequent that they alarmed even the healthful with appre- 
hensions of sudden Death. The Cause of this Epidemick Apoplexy is justly im- 
puted to the unusual Constitution of the Weather in those years. The Summer of 
1693 was so extream hot and scorching, which was followed by nipping cold 
Weather, in the beginning of 1694, and, contrary to the Custom of Italy, with a 
rigid Frost, Snow, and Ice. * ^- * The Summer after that was much hotter than 
the former, insomuch that for five Months together there was no Rain. About 
the beginning of October it began to be wet weather, and continued such, with 
a Southerly Wind to April, 1695, and that to such a degree that so much Rain was 
not seen to fall at one time within the memory of Man. After fifteen days of 
continued Rain, perhaps we had two days clear Weather, which were followed by 
heavier Rains than went before. After this uncustomary Weather, the above- 
mentioned Apoplexies display'd their Rage ; and perhaps some part of the Epide- 
mick illness was owing to the Universal G-rief and Domestick Care, occasioned by 
such calamitous times ; all Europe being at the same time engaged in a sharp 
War, the like of which has scarce been heard of since the Foundations of the 
Universe were laid. So many Cities were raz'd and burnt; so many thousands 
of Men slain ; all Commerce disturbed, and the Avenues of Peace block'd up, 
that the strongest heart could not bear the Thoughts of it."' 

' " The Practice of Physick reduced to the Ancient way of Observations. Contain- 
ing a Just Parallel between the wisdom and experience of the Ancients and the 
Hypotheses of Modern Physicians, &c. &c. Written in Latine by Geo. Baglivi, M. D., 
Professor of Physick and Anatomy at Rome. Printed for Andr. Bell (ef al.). Lon- 
don, 1704." 



1859.] 



Levick, Remarks on Sunstroke. 



49 



Further on tie mentions that numerous earthquakes prevailed at this 
time, that many people were pinched with famine, and that the plague in- 
vaded one of the smaller towns shortly before. 

While among the ancients, I may be permitted to quote from old Fo- 
RESTUS,^ who, in a series of observations on apoplexy (which for careful 
investigation and accuracy of description, may well put to the blush more 
modern writers), has this sentence: "And we have ourself seen, in the year 
1562, when the condition of the atmosphere {constitutio dsris) was humid 
and rainy, and the south wind had existed for a long time, very many per- 
sons to have perished by apoplexy." He then describes a number of cases 
under his care, mentions certain streets and villages as especially affected, 
and designates many of the attacks as mild apoplexy (levis apoplexia), 
from which recovery speedily took place. He recommends, among other 
remedies, stimulating frictions, and speaks of bleeding as unnecessary in 
many of these cases. Hillary,^ in a work on tropical diseases, states that 
apoplexies are of frequent occurrence in Barbadoes in the month of July. 

Now, I do not for one moment suppose, that all the cases thus recorded 
as those of apoplexy, not even all those designated as "levis apoplexia,''^ 
were cases of sunstroke, the pathological researches of Forestus show the 
contrary ; but I cannot forbear calling attention to the fact, that the cir- 
cumstances attending their development were closely analogous to those 
which are mentioned by modern writers as attending and as producing 
sunstroke — "the south wind long existing;" the humid atmosphere as 
given by Forestus; the long hot and dry followed by the moist atmosphere; 
the conditions which precede (as before quoted from Gordon), and which 
resulted in earthquakes, as related by Baglivi ; the mental distress preva- 
lent in the community at the time, all these find their appropriate place, 
and accurately fit in the picture already given as descriptive of what we 
now call by the varied names of sunstroke, insolation ; exhaustion from 
heat. Might we not without violence thus explain what otherwise it is 
difficult to explain, an epidemic of apoplexy? Descriptions similar to 
those already given, I find in an old copy of Lancisi,^ who recommends 
the preparations of iron in the debility following such cases. 

To return to the nature and post-mortem appearances of sunstroke, the 
first fact which meets us, and which very much interferes with a satisfactory 
investigation, is the rapidity with which putrefaction occurs. In two fatal 
cases which came under my notice during last summer, decomposition had 
occurred ten hours after death to such an extent as to render a post-mortem 
examination impossible. The exterior of the bodies was of a deep livid 

' Domini Petri Foresti, M. D., Observationum et Curationum Medicinalium ac 
Chirurgicarum opera omnia. Francofurti, 1634. 

2 By Wm. Hillary, with notes hj Benjamin Rush, M. D. Philad., 1811. 
^ Jo. M. Lancisii, M. D., Opera omnia in unum Congesta. Venetiis, 1739. 



50 



Levick, Remarks on Sunstroke. 



[Jan. 



colour, horribly offensive discharges had taken place from the mouth and 
nostrils, and the surface imparted to the hand the soft boggy sensation so 
characteristic of decomposition. 

Until the appearance of Mr. Russell's paper {vide supra) under the 
impression that the disease was allied to, if not identical with apoplexy, 
the attention of necroscopists appears to have been directed exclusively 
to the brain. Andral, in describing his cases of cerebral congestion, before 
quoted, gives a faithful description of the appearances now recognized 
as existing after sunstroke. Though meant to illustrate cerebral disease 
as produced by heat, with his usual accuracy, he states that with the 
exception of engorgement of the vessels of the meninges, there was no 
diseased condition of the brain other than softening, while the pulmonary 
vessels were equally as much engorged as those of the dura and pia mater. 
Russell (loG cit.), much to his surprise, found no lesion of the brain, though 
he had been taught to expect it. He states, "the brain was in all healthy ; 
no congestion or accumulation of blood was observable, a very small quan- 
tity of serum under the base of one, but in all three the lungs were con- 
gested even to blackness through their entire extent, and so densely loaded 
were they that complete obstruction must have taken place. There was 
also an accumulation of blood in the right side of the heart, and the great 
vessels approaching it." 

Dr. Gerhard had before this time noticed a similar condition of things. 
In his clinical lectures (Graves & Gerhard) p. 6tt, he says : ''During the 
intensely hot weather of the summer of 1830, I witnessed the opening of 
thirty persons who died from the effects of heat ; we found no organic dis- 
ease of the brain, but merely a slight congestion, such as is observed in 
other acute diseases, which it would be idle to set down as a cause of death." 
Dr. Pepper in his examinations (many of which I witnessed), found that 
"the brain exhibited no indications of congestion, nothing, in fact, of an 
unusual appearance. But in all of the four subjects the heart was pallid, 
flaccid, and softened, while the other muscles of the body were florid and 
firm. The lining membrane of the heart and of the large bloodvessels was 
of very dark, almost purple colour. The cavities of the heart contained 
but little blood and no coagulum." Similar appearances are reported by 
Drs. Lente and Swift. Dr. Dowler found "intense congestion of the lungs, 
and believes the cause of death, secondarily, perhaps, to be here." All these 
observers agree in representing the blood as fluid, and in a letter from Dr. 
B. Darrach, now Resident Physician New York Hospital, describing the 
inspection of a fatal case occurring in the hospital last summer, he has 
written " the most interesting and remarkable appearance was the frothy 
fluid condition of the blood, and the distension of the heart with gas." (See 
following article.) 

Now, no intelligent medical observer can witness, or read of these phe- 
nomena, without being struck with their resemblance, I had almost said 



1859.] 



Levick, Remarks on Sunstroke. 



51 



their identity with those presented in deaths from typhus fever. Take any 
of our standard authorities, Wood or Gerhard, e. g., and compare their de- 
scriptions of the pathological appearances of typhus with those above 
given. 



Post-mortem Appearancesin Ti/phus Fever. 

A strong tendency to speedy putrefac- 
tion. — Wood. 

Petechial eruption a cliaracteristic le- 
sion. — Wood. 

Blood found in tlie veins liquid ; coa- 
gula rare. Within the cranium there is 
often venous congestion, with some se- 
rous eifusion in the ventricles or beneath 
the araclmoid ; and the substance of the 
brain is occasionally darker than in 
health, though in other cases unaltered 
or even whiter. No clearly ascertained 
connection exists betweeen the stupour 
and the anatomical appearance in the 
brain. — Wood. 

The posterior and lower part of the 
lungs is often solidified ; of a dark red 
colour, fragile, and impervious to air, 
though without the granular appearance 
of hepatization. — Wood. 



The heart sometimes natural, some- 
times softened, sometimes containing 
liquid blood. — Wood. 



Post-mortem Appearances in Sunstroke. 
Speedy decomposition after death. — 

DOWLER. 

Face and neck covered with livid spots. 

^ — DoWLER. 

Petechi^e. — Andral. 

Slight congestion such as occurs in 
other acute disease ; no organic disease 
of the brain. — Gerhard. 

Brain healthy ; a very small quantity 
of serous effusion in some cases ; venous 
congestion ; brain healthy, substance 
soft. — Andral. 

In a case of stupour and delirium no 
lesion of the brain found. — Swift. 



Lungs dark and injected with blood ; 
the central and posterior parts present- 
ing the appearance of an enormous clot 
of blood, somewhat solid, and united by 
a texture bearing no resemblance to the 
elastic, contractile texture of healthy 
lung. — Dowler. 

Heart soft. — ^^Pepper. 
" natural. — Lente. 

Heart filled with liquid blood. — An- 
dral, et al. 



And so too with the incidental lesions of other viscera. 

If we carry our investigations further back, we shall find an astonish- 
ing identity in the symptoms presented during life. Each has a frequent 
and feeble pulse, each may or may not have a hot, pungent skin, each has 
its stupor deepening or not into coma, each its suffusion of face and eyes, 
its lividity of countenance, and we need but use the words given as descrip- 
tive of typhus, if we would describe some of the phenomena of sunstroke, 
"Now and then great restlessness and jactitation occur, with twitching in 
various parts of the body;" while, as if to complete the picture, I find a 
ease of sunstroke reported in which epistaxis, a frequent attendant of 
typhus fever, existed. 

These facts would seem to indicate that there is in sunstroke as there is 
in typhus fever a poisoned condition of the blood, and that it is to this that 
we are to refer the various morbid phenomena of the disease, an explanation 
which has also been given in cases of death from lightning. I cannot, how- 
ever, divest my mind of the belief that in sunstroke this unnatural condition 
of the blood is a secondary affection, not the primary one ; that there is in 
the first place an exhaustion or depression of the nerve-forces which regulate 
nutrition, respiration, circulation, and the other acts of organic life. A 



52 



Levick, Remarks on Sunstroke. 



[Jan. 



condition to some extent analogous to this we liaye in congestive or perni- 
cious fever, and perhaps also in cholera, though in neither of these diseases 
have we proof that the blood is poisoned. What are the various circum- 
stances required to develop these results, and what the exact order in which 
they are produced we cannot positively say. We know so little of the 
nature of the vital force in its healthy condition that we can expect to 
know but little of the cause of deviations from the healthy standard. 
We can speculate, and we may draw our inferences as to the treatment, 
and watch for its results. If we adopt the theory recently proposed 
with much plausibility by Dr. Davey, that the so-called ganglionic system 
affects directly or indirectly all varieties of abnormal action, we must of 
course look to it for the first link in the chain of these phenomena. The 
vital force, place it where we will, is so affected by the modification of 
temperature, of meteoric or other condition of the atmosphere, that the 
conservative or regulating influence and supply of proper nerve power is 
lost in part or in whole. Hence result feeble action of the heart, imper- 
fect respiration, stases of blood in the lungs, in the brain, loss of vitality 
of the blood, and the tendency evinced even during life, and still more in 
death, to rapid putrefaction. Just as we see, suggests Davey, under local 
depressing influences, slowly produced, fatty, amyloid, and other degene- 
rations. Similar phenomena occur at either extremity of the thermome- 
trical scale. Baron Larrey reports, as the result of the retreat from 
Moscow when the depressing influences of defeat were added to those of 
fatigue and of cold, that many perished from dizziness, vertigo, somnolence, 
ending in profound coma, and death. (Andral, loc. cit.) 

If we would remedy these things we must direct our attention to the 
condition of system producing them, not to the mere phenomena them- 
selves. We must not rely on local measures to relieve the congestion of the 
lungs or of the brain, but just as we would do in typhus and pernicious 
fevers, we must remedy the evil producing these congestions. That there 
may be congestions we do not doubt, but in most instances they are passive 
congestions — a stasis of blood from want of the usual motive power. Post- 
mortem inspections in all these diseases show us this, and death is often 
produced by a treatment based upon different views as to their nature. 
And yet bleeding has been the treatment practised by many even to the 
present time. Not to mention those of earlier date. Dr. Gordon, as late as 
last year, reporting 28 cases, only one of which recovered, seems to have 
bled every case. The solitary survivor is said to have undergone the follow- 
ing heroic treatment: "Slight cautery to the nape of the neck, opening of 
the right temporal artery, and, while the patient lay unconscious, a power- 
ful jet of water was directed on the head and epigastrium, croton oil being 
exhibited internally!" Without quoting separately each author, let me 
here state that nearly all our American writers agree that bleeding, so far 
from being of advantage, generally hastens a fatal termination. Dr. Beat- 



1859.] 



Levick, Remarks on Sunstroke. 



53 



son (loc. cit.), after giving a fearful history of the results of bleeding in such 
cases, says of three cases treated by him all recovered. His plan of treat- 
ment was "to unfasten as quickly as possible the man's dress and accoutre- 
ments, to expose the neck and chest, get him under the shade of a bush, 
raise his head a little, and commence the affusion of cold water from a 
sheepskin bag, continuing the affusion, at intervals, over head, chest, and 
epigastrium, until consciousness and the power of swallowing returned. 
When this takes place the affusion may be stopped, and a stimulant mix- 
ture given occasionally in small doses." 

I believe this to be, with some modifications, the treatment called for. 
In typhus and in pernicious fevers, we find cold affusions to have been long 
used, and with advantage ; but, as in them so in sunstroke, I can readily 
conceive there may be instances in which the powers of life maybe so spent, 
as to fail to respond to the shock of the cold, and the existing depression 
be thus increased; nor in any case should they be persevered in after the skin 
begins to assume a moist and healthy condition. So, too, in regard to the 
use of ice to the head, which is not to be resorted to indiscriminately. 
Where the individual can readily swallow, recourse may at once be had 
to stimulants, of which ammonia, in some form, is the one most fre- 
quently used. The carbonate of ammonia, in gr. v — gr. x doses, and the 
aromatic spirit, have been used by me with advantage. In the New York 
Journal of Medicine for 1854, p. 58, Dr. J. R. Leaming urges the use 
of muriate of ammonia in eight-grain doses every half hour. The cases 
are not very fully reported, and the pulse is described as sloiu and weak — 
a condition I have never seen in sunstroke. Dr. Dowler quotes from a 
German medical journal what purports to be "a most efficacious remedy 
in coup de soleil:. acetic ether dissolved in wine vinegar, to be applied as 
a lotion on the forehead, temples, cheeks, hands, and chest, and the same 
to be given every half hour with coffee."^ 

Unless swallowing can be readily accomplished, I think it best to avoid 
the exhibition of remedies by the mouth, as, passing into the trachea, they 
often occasion unpleasant coughing and distress. In the cases mentioned 

* Since the above was written, I liave seen an interesting paper in the London 
Lancet, by J. R. Taylor, Esq., Deputy Inspector of Hospitals, on " Erethismus 
Tropicus," the name given by the writer " to the state of system which exhibits 
the acute effects of continued high tropical temperature on the European." Some 
of the cases therein recorded presented the ordinary phenomena of sunstroke, 
while in others the symptoms seem to have been modified by an epidemic of 
cholera which had preceded, and, as I believe, left its impress on the subsequent 
epidemic. The reports of these cases coincide in many respects with those I have 
given. The subjects of the attack were "men of remarkably stout build," but 
unacclimated. The pathological appearances differ but little from those given 
above, and the author of the paper recommends as the most effective treatment, 
cold affusions and the avoidance of venesection as a general rule. (See London 
Lancet for August 21—28, 1858.) 



64 



Levick, Remarks on Sunstroke. 



[Jan. 



by me at the College of Physicians, I ventured to suggest that there might 
be a special value in the oil of turpentine, whether given by the mouth or, 
as in the cases there reported, by the rectum. I would again mention this 
remedy, and strongly urge its trial. As a stimulating enema, it has long 
been used, but it may be more than this ; and the results in the cases 
alluded to were, to say the least, gratifying. It was prescribed in doses of 
f^j of oil of turpentine, in a half pint of liquid, every half hour, until re- 
action began. Of the value of oil of turpentine in typhus and other malig- 
nant fevers, in scurvy and other altered conditions of the blood, there is 
strong evidence. In typhoid fever, we all know it to be useful, and the 
results of the cases treated recently in the hospital confirm me in the belief, 
that in sunstroke, which, as we have seen, resembles typhus fever in so 
many of its features, it is also of especial value. Nor is it a new remedy, 
even in cases regarded as apoplexy. Forestus, before quoted, in his cases 
of mild apoplexy which recovered, used, as one of his most efl&cient agents, 
the oil of turpentine. I may here quote from the Transactions of the 
College the following passages : — 

"If one principle were more insisted on than another in the treatment of 
these cases, it was the importance of avoiding any expenditure of the little 
remaining strength of the patient. Though recommended in such cases, 
the full bath is not without danger. The chief indication for its use is 
found in the stimulus afforded by the liot bath — for which, in practice, the 
warm bath is often substituted — the depressing influence of which may 
fatally exhaust the forces which barely maintain the balance between life 
and death. * * During this time, the patient should have his feet 
placed in a strong mustard foot bath, but without any exertion on his 
part. When able to swallow, brandy, wine whey, or, as before mentioned, 
ammonia may be given him." 

In a recent visit to the New York Hospital, I was told by Dr. B. Dar- 
rach, one of the resident physicians, that, to relieve the burning heat of 
the skin — which is justly viewed as a most unfavourable prognostic symp- 
tom — it had occurred to him that frictions of the body with ice might be 
useful, and that he had carried out the suggestion with very happy results. 

After the immediate symptoms of an attack have passed, as after cholera, 
typhus fever, &c., so with sunstroke, various internal inflammations may 
be developed — as of the brain, the lungs, &c. — which require a treatment 
entirely unlike that mentioned above. In this way, we have cases reported 
as meningitis resulting from exposure to heat; but, according to my obser- 
vation, these differ from sunstroke in their gradual mode of attack, although 
just as apoplexy may occur in warm weather, so may meningitis ; but in by 
far the greater number of cases of sudden attacks of illness from exposure 
to heat, inflammation of the brain is not the pathological condition. Nor 
must we be misled by the presence of delirium, or of a hot skin, in such 
cases. The latter we have present even in malignant typhus, and no fact 



1859.] 



Darrach, Exhaustion from Heat. 



55 



is better known to the pathologist than this : that, in typhus and typhoid 
fever, phenomena almost identical in character with those of inflammation 
of the brain may be present, and yet, after death, no lesion of this organ 
be found. In the words of Dr. Bartlett, when writing of typhus fever, 
"Delirium and somnolence have occurred as frequently, and as strongly 
marked, in patients whose brains presented no changes, as in those of an 
opposite character." 
October 14, 1858. 



Art. III. — Gases of Exhaustion from Heat treated in the New York 
Hospital by Stimulants and Ice to the entire Surface of the Body. 
Reported by B. Darrach, M. D., Resident Physician. 

Case I. Daniel Murphy, 8et. 29, native of Ireland, labourer, was admitted 
August 14, 1857 ; brought by the police from a drug-store,, without any his- 
tory of his attack. Comatose; skin burning hot, but moist; respiration 
40 per minute, stertorous, laboured, and sighing; pulse 160, and feeble ; pu- 
pils contracted, and insensible to light; eyes congested; has great difficulty 
in deglutition ; vomited before admission. Ordered an enema of carbonate 
of ammonia and brandy, ice to the head, and sinapisms to the chest, abdo- 
men, and thighs. While under this treatment, the intense heat of skin 
seemed to indicate some attempt to reduce it. Ice was accordingly applied 
to the body, at first cautiously. In half an hour he vomited some green 
fluid, and had a tetanic convulsion of the muscles on the back of the neck. 
Pupils dilating, and show signs of sensibility. Ice applied more freely, 
being rubbed over the whole body and down the arms and legs. Sinapisms 
removed. Three hours after admission he had a violent convulsion ; pupils 
dilated, and sensible to light; the heat of skin still kept down by ice. 

Aug. 15. The ice was applied at short intervals through the night. Pa- 
tient was conscious this morning; but now, 11 A. M., is semi-comatose. 
Pupils contracted; skin comfortable; tongue dry and brown, with sordes 
on the teeth; pulse 108 to 120, feeble. Treatment suspended early this 
morning. 

1 Uh. Yesterday afternoon he was able to give his name and age, but 
spoke so indistinctly that nothing else could be understood. Has an idiotic 
expression of countenance. 

20^/?. Notices himself a difficulty in his articulation, though it is very 
much improved. Says that on the day he was taken sick he had felt bad 
all day ; had drank four or five glasses of brandy, and freely of cold water. 

^%th. Still speaks indistinctly, but is otherwise perfectly well. Discharged. 

Case II. Marie Hass, est. 19, German emigrant just arrived, admitted 
June 26, 1858. Had been running about all day. Was said to have had a 
slight attack of sunstroke in the morning. Ate a hearty dinner, and drank 
freely of beer and ice-water. Was taken suddenly sick on the Erie Railroad 
Pier about 3 P. M., and brought to the hospital about three hours after- 
wards. On admission she was insensible, with violent convulsions; skin 



56 



Darraoh, Exhaustion from Heat. 



[Jan. 



burning hot, and pungent; pulse 135, small; pupils contracted ; respiration 
hurried, but easy; vomiting. Ordered ice and iced brandy freely ; carbonate 
of ammonia, grs. v, every quarter of an hour ; to be rubbed from head to 
foot with ice constantly; ice kept to the head. T P. M. Pulse 116; respi- 
ration 36 ; skin cool while the ice is applied, but becomes hot as soon as it 
is stopped ; convulsions less. Continue treatment. Pell asleep at ^ J P. M. 
Kespiration easy ; pulse much less frequent. Treatment suspended. Woke 
in a convulsion half an hour afterwards, but slept immediately after it, and 
was not disturbed through the night. 

June 2t. Pulse natural. Appears and feels well. Wants to go. Dis- 
charged. 

Case III. Unknown man, apparently a German baker, set. about 22, ad- 
mitted June 28, 1858. Was taken suddenly in a store in Seventeenth St., 
nearly two miles from the hospital. Admitted three hours and a quarter 
after. Insensible; pupils contracted ; pulse 150, small and feeble; respira- 
tion 34, laboured and sighing; skin hot and pungent; has sinapisms on 
his feet, wrists, and abdomen; tongue hot; unable to swallow. Gave two 
ounces of brandy by stomach-pump ; rubbed the surface with ice from head 
to foot ; ice to the head. Forty minutes after his face became livid, with 
irregular respiration, dilated pupils, then a short struggle and death. 

Case IY. Mary Duffy, set. 40, native of Ireland, married, admitted June 
29. Distressed looking, ragged creature. As ascertained afterwards, she 
had been complaining for a week, but kept at her work as washerwoman ; 
and to-day, though suffering a pain in the stomach, took a long walk in the 
sun. She drank freely of water, and once of gin. Was taken with blindness 
about the middle of the afternoon, while in the street. When brought in 
by the police she was so far insensible as to be unable to answer, but repeated 
the question until asked another. Pulse 160; respiration 40, sighing, but 
not very laboured; skin hot. Took brandy ^vj in the course of two hours, 
and was rubbed with ice as the others, keeping the skin cool. An hour 
after admission she could tell her name and express her gratitude. Pulse 
112; respiration 18; surface cool. Complained of pain in the head; re- 
lieved by ice. Had some spasmodic respiration for a few minutes, but after- 
wards became natural. 

June 30. Slept well; feels sore this morning. 

July 2. Feels well; gaining strength. Has a constant tremor of the 
eyes. 

IQth. Eyes well. Discharged. 

Remarks. — Of all the cases — four in number — treated in the hospital 
during the last two summers, by stimulants, sinapisms to the extremities 
and body, and ice to the head, none were more grave on admission than 
those recorded above, and none recovered. Dr. H. S. Swift, in a paper 
published in the New York Journal of Medicine, vol. ii., 1854, gives an 
account of sixty cases which occurred in the hospital under his care, of 
which thirty-three died. He has also collected the cases in the hospital for 
about thirty years back, and found 150, of which "78 died. None of the 
cases admitted under my observation were of a mild form, the first stage of 
Dr. Swift. Two of those which recovered had contracted pupils, a uni- 
formly fatal symptom with the doctor. In the other recovery the pupils 



1859.] 



St ORE R, Use and Abuse of Uterine Tents. 



61 



were not noted. In BraitJmaite^s Retrospect, vol. xxxvii., page 363, is 
a paper from the pen of Dr. Beatson, army surgeon in India, whose treat- 
ment, as given there, was affusion of cold water to the head, chest, and 
epigastrium, with moderate stimulation; all ligatures about the neck being 
removed, and the patient, if possible, carried to the shade. He was uni- 
formly successful in eight or ten instances, in all of which the treatment 
appears to have been applied immediately. In my own cases the ice was 
rubbed over the surface until it became cool and the pulse diminished in 
frequency. Of those that recovered, it was continued on one of them, with 
little or no interruption, until she slept, a period of one hour and a half ; 
in another an hour, when she was able to give a correct account of herself, 
and the pulse was reduced from 160 to 120 beats per minute; in the other 
it was continued at intervals for twelve hours. Any increase of the heat of 
skin or permanent frequency of pulse being considered an indication for the 
ice. All the cases of the past season were admitted after 3 P. M., and after 
the daily visit of the Attending Physician, Dr. Joseph M. Smith, though 
the treatment met his subsequent approval. Case I. was treated by Dr. 
Thos. B. Dash, then Resident Physician, at the suggestion of the writer. 
New York Hospital, September 17, 1858. 



Art. IY. — The Use and Abuse of Uterine Tents. 
By Horatio R, Storer, M. D., of Boston. 

Expansible tents, for dilating the os and cervix uteri, though of com- 
paratively recent introduction into this country, are already somewhat 
extensively in use. Like all other obstetric agents, they are still too often 
neglected; and, on the other hand, like the speculum, the caustic, the 
pessary, they are too often misemployed. In consequence of these facts, 
and in the hope, by elucidating one point of medical responsibility, directly 
to save human life, the present paper has been written. 

Uterine tents, when expansible, are intended for the following pur- 
poses : — 

I. To induce premature labour ; 
II. To assist accidental abortion ; 
III. To aid or to hasten the progress of labour at the full time ; 
IY. To expose the uterine cavity for purposes of diagnosis or treatment, 

in diseases puerperal ; and, 
Y. In diseases non-puerperal. 

In each of these classes I propose briefly to consider their use, and in 
each their abuse. 



58 



Storer, Use and Abuse of Uterine Tents. 



[Jan. 



I. The Induction of Premature Labour. — Tents for this end, first sug- 
gested by Kluge and Brunninghausen, long used on the continent of Europe, 
and in 1844 introduced into Great Britain by Simpson, have their advan- 
tages and their disadvantages. They are comparatively speedy in their 
action ; this action is in imitation of natural processes, both as regards 
dilatation, and in keeping the membranes entire ; they are unattended with 
much risk to the life either of mother or child. 

On the other hand, their introduction is not always easy, more especially 
if pregnancy be near its close, and the os not readily reached ; their action 
is often accompanied by much uneasiness and severe pain, entirely uncon- 
nected with that from uterine contractions ; their rapid decomposition, if 
of sponge, may predispose to or occasion puerperal disease. 

They must be compared with other means, to show their real and relative 
value. 

All so-called oxytoxic medicines, not even excepting ergot, are unreliable 
or dangerous, either to mother or child. 

External manipulations or frictions, forced exercise, the use of electricity 
or galvanism, mammary irritation, are alike unscientific ; if they succeed, as 
is by no means always the case, they are alike dangerous. They would 
excite contractions of the uterus before any dilatation of its orifice has 
taken place, or any detachment of the membranes from its walls; processes 
preliminarily essential to safe and normal labour. The tendency of such 
premature contractions is, as is shown by innumerable cases on record, to 
destroy the foetus, by cerebral effusion from long-continued pressure, and to 
destroy the parent, by rupture of the uterus, or by hemorrhage attending 
or subsequent to delivery, or by the wear and tear of a lingering labour. 

The objections now alleged apply with even more force to puncturing 
the membranes, the process formerly and probably still most frequently re- 
sorted to. Here, it is true, there is generally some slight dilatation from 
the passage of the instrument used, whatever this may be. But the sup- 
plementary aid of the wedge-like bag of water is lost j and the pains, more 
quickly as mi ore certainly occurring, find the uterus and its contents equally 
unprepared. Statistics from eminent practice prove the great mortality, 
both fcetal and maternal, attending this method. 

Dilating the os and detaching the membranes by the injection of water, 
whether direct or secondary in action, has also its objections. By the first 
of these processes, I mean where the fluid at once and directly enters the 
OS ; and by the second, its reception and retention by the vagina, acting on 
the OS, not, as has been supposed, by relaxation from imbibition, but only 
by pressure from below : cruel, because extremely painful ; unadvisable, be- 
cause tedious and uncertain ; unjustifiable, because endangering laceration • 
of the vaginal attachments to the cervix. The direct douche is liable to 
cause foetal rotation and malpresentation, is tedious and must generally be 
repeated a number of times, and involves as much and even more danger 



1859.] 



Storer, Use and Abuse of Uterine Tents. 



59 



than the subsequent method, of premature detachment of the placenta and 
serious hemorrhage. 

Compared with the above operations, tetfts are best. They should, 
however, be preceded" in use by some slender staff, sound, or catheter, intro- 
duced to detach the membranes, too early separation of the placenta being 
guarded against by careful auscultation. 

Wherever, in these cases, the tent does not seem absolutely necessary, its 
use should be dispensed with. If required, it should be as accompanying 
the process last described, the two mutually aiding and reacting upon each 
other. These points are already familiar to the profession ; they are here 
recapitulated, as bearing upon a question too often lost sight of, that of 
medical responsibility. 

If the premature labour, actually an abortion, and attended, in proportion 
to its period, with the general risks of such — is not absolutely indicated to 
save one or other of the two lives at stake, it becomes criminal; and 
accountable, morally and legally, as such. 

II. The Assistance of Spontaneous Abortion. — We have above alluded 
to the abuse of tents in inducing intentional abortion. 

If this, however, be accidental, or from natural causes ; if, having com- 
menced, its progress seems unavoidable ; preventive measures having failed, 
or being out of the question from the presence of pressing and dangerous 
symptoms, while the uterus undilated cannot discharge the ovum, it may 
become not merely justifiable but imperative to use tents. In this instance, 
they may act not only as a mechanical dilator, but also as an uterine plug 
or tampon, restraining hemorrhage by its own backward pressure. The 
state of things, in early abortion particularly, being very different from that 
in labour at the full time, little danger is thus incurred ; the uterine cavity 
small, and its walls unyielding, its tissue turgid^ and thereby the entrance 
to the Fallopian tubes closed. 

III. The Assistance of Timely Labour. — In but a single instance are 
tents likely to be of aid, after a labour at the full time has fairly commenced ; 
and this, not forgetting its complications with convulsions, placenta prsBvia, 
and the like, where there is excessive rigidity of the os uteri. If pains are 
strong, however, it is almost impossible to introduce, or to keep in position, 
a tent of any size ; and if they are not strong, it is often a better practice, 
unless some compli(;ation is present or threatened, to delay for a time instead 
of hastening the progress of the labour. In almost every instance, other 
irritation — direct, by digital expansion or stimulating applications, pro- 
voking increased discharge of mucus, or sympathetic, as from enemata, 
especially of tartrate of antimony* — is of much more marked and immediate 

' The above treatment, first practised in tliis country by tlie writer (Boston Med. 
and Surg. Journal, Feb. 1856, p. 38), has since been successfully followed in very 
many reported cases. 



60 S TOREK, Use and Abuse of Uterine Tents. [Jan. 

avail. Better often, by judicious interference, to subject a patient to its 
trifling risk, than by delay to let her incur the proportionately increasing 
one in such cases usually obfeining ; and this despite any advice that may 
be offered to the contrary.^ •* 

TV. Dilatation in Puerperal Disease. — Hemorrhage subsequent to 
labour, and continuing for several days, over-abundant or extremely fetid 
lochia, accompanied, perhaps, by excessive after-pains, are not uncommon ; 
and if the discharges are profuse, they become at once alarming and danger- 
ous. They may be owing to retention of a fragment of the membranes or 
placenta, loose or adherent, or to that of a blood clot ; much more rarely 
to persistent want of general uterine contractility, or to a true secondary 
hemorrhage from the wound left by detachment of the placenta. In the 
instances referred to, the retained foreign body, whatever it be, is some- 
times thrown off by nature unaided, at other times not. 

A better practice than to exhibit drugs or throw up injections, is to dilate 
by tents, and then, if necessary, remove whatever may be found by long and 
slender forceps. Three cases have now been treated in this manner by the 
writer, two of them in consultation, all of them successfully. 

In other instances, acute or chronic, of malpractice or accident, as where 
the head or other foetal fragment may have been left in the uterus ; or of 
simple disease, as of retention, in whole or in part, of the product of con- 
ception, whether as mole, hydatids, skeleton, or mummy, the applicability 
of tents is no less evident. 

Y. Dilatation in Diseases unconnected with Child-bed. — Except dur- 
ing delivery, and for a short time immediately subsequent to it, and in a 
few cases of organic disease, attended with shortening or loss of the cervix 
and abnormal laxity of the os, the diseases of the interior of the uterus, of 
its walls, and of the lining membrane, were, till 1844, utterly beyond every 
power of diagnosis, and of treatment, unless empirical. The evidence, only 
afforded by functional or reflex symptoms, or by morbid discharges, often 
equally misleading, was wholly insufficient for the one ; the use of uterine 
injections, the only topical application then possible, was too blind, and, 
therefore, too dangerous for the other. 

At the present time, however, the cavity of the uterus has been brought 
by tents almost as completely within reach as its cervix, and I repeat even 
more emphatically than formerly, that as ''without the sound no man can 
satisfactorily diagnose some of the diseases of women, without the tent 
there are others that no man can cure."^ 

Intra-uterine malignant disease, polypi, sessile tumours, are thus brought 
under control, and local applications, medicinal or otherwise, understand- 
ingly made. In its proper place resort may be had to various instru- 

' As for instance, in this Journal, Oct. 1858 : "Evils of Meddlesome Midwifery." 
2 Preface to Simpson's Obstetric Works, 1855. 



1859.] 



S TOREK, Use and Abuse of Uterine Tents. 



61 



mental aid, by tlie curette, knife, ligature, simple or in the double-action 
ecraseur, applied by Drs. Savage^ and Priestley,^ of London ; or to powerful 
caustics, as the hydrate of potash, proposed by myself,^ and put into suc- 
cessful practice f used of course, all of them, with extreme care and circum- 
spection. 

In one rare class of cases, vesico -uterine fistulee, tents serve the diagnosis, 
not by their dilating power, but as a plug ; retaining the urine till, by an 
appreciable quantity, its escape is made to show its source. They may, 
perhaps, ultimately render possible some method of treatment. That 
tents for uterine dilatation, as generally made of sponge, are attended 
with certain risks, unless of the softest and finest quality, evenly shaped, 
and in use cautiously watched, and that a substitute for this material, of 
equal efficacy, would be a valuable acquisition to practice, I have elsew-here 
endeavoured to show.^ Of slippery elm, then proposed, use has been made 
in mechanical dysmenorrhoea, with the advantage claimed and expected ; 
but in other cases the desideratum remains unsupplied. Suggestion of 
metallic dilators, in many forms, has been made by an ingenious friend, 
Dr. Graham AVeir, of Edinburgh ; but in practice they have been found 
useless, irritating, dangerous. 

It might seem superfluous to add a caution, lest by tents abortion be 
accidentally and unintentionally induced. Two cases in the practice of 
friends, however, have satisfied me that the risks are much greater than 
they might seem. Upon this point I shall speak more fully in another 
connection,^ and here merely state, as the safer rule, that since it is abso- 
lutely impossible to be sure of the absence of pregnancy in the earlier 
months, and since an abortion thus produced is not merely a loss to society 
in itself, but also in far greater proportion as encouraging others by seem- 
ing carelessness of foetal life, tents should not be used, or the uterus other- 
wise disturbed, where the woman is at all liable to pregnancy by marriage 
or other chance, till the short time sufficient to establish the diagnosis has 
been allowed to elapse. Of course cases of hemorrhage, of an os partly 
open, or occupied by a foreign and protruding mass, afford evident excep- 
tions to the rule now proposed. 

To sum up then this subject, it may be stated that to produce premature 
labour and necessary abortion, to assist accidental abortion and the pro- 
gress of labour at the full time, to aid or rather to render possible the 

» Lancet, Nov. 1857, p. 524. 

2 Med. Times and Gazette, Jan. 1858, p. 115. 

3 Bost. Med. and Surg. Journal, July, 1856, p. 500. 

4 Ibid., Nov. 1857, p. 288, and Oct. 14, 1858. 

5 Association Med. Journal, London, May, 1855, p. 446; Boston Med. and Surg. 
Journal, Nov. 1855. 

6 Contributions to Obstetric Jurisprudence. No. 1, Criminal Abortion. N. A. 
Med.-CMr. Rev., Jan. 1858. 

No. LXXIII.— Jan, 1859. 5 



62 Packard, Affections of the Spinal Column. [Jan. 

diagnosis and treatment of various forms of puerperal and of non-puerperal 
disease, the use of uterine tents become not only justifiable, but at times 
imperative ; that when resorted to carelessly, rashly, or for a criminal pur- 
pose, their use becomes an abuse ; and that when being indicated, they are 
knowingly neglected or omitted, and in consequence, as still not unfrequently 
happens, a human life lost, the physician in charge directly becomes, and 
should be considered responsible therefor. 
Chester Park, 25 Oct. 1858. 



' Art. V. — Remarks on some Affections of the Spinal Column. 
By John H. Packard, M. D., of Philadelphia. 

There are several reasons for the paucity of our definite knowledge in 
regard to the diseases and injuries of the spinal column ; one of the chief 
of which is that many of those affections are either so easily reached by 
ordinary remedies, or so hopeless from the outset, that their careful inves- 
tigation seems a matter of no moment to those who have them in charge. 
Moreover, post-mortem examinations in these cases are attended with more 
difficulty, and require more laborious and careful dissection, than almost 
any other ; nor is it always easy to obtain permission to make them. 

The vertebrae, from the atlas to the coccyx inclusive, are to a great 
degree protected from the ordinary forms of violence ; and this is due not 
only to their form, connections, and situation within a muscular mass, but 
also to the fact that in the falls which constitute the most common source 
■of injury to them, the head and extremities are very apt to exhaust the 
force of the shock. But there is a variety of indirect violence not men- 
tioned in the books, which is nevertheless of some importance ; I allude to 
powerful pressure at or near each extremity of the chain of bones. The 
following case will serve to illustrate its effects upon the false vertebrae. 

A coal-miner was sitting upon a large piece of coal, and bending forward 
to his work, when a mass was detached just over his head, and came down 
upon him. The force thus brought to bear was immense, and its results 
were in proportion ; the sacrum was fractured transversely as well as longi- 
tudinally, and its lower extremity was comminuted, as was also the coccyx; 
the right sacro-iliac symphysis was forced open ; the horizontal ramus of 
the pubis of each side, and the ascending ramus of the ischium of each side, 
were fractured. There was also a fracture of the left tibia, and a complete 
rupture of the urethra. 

When force of this kind acts upon the true vertebrae only, it may have a 
very singular effect. A young man. It years of age, was admitted into the 
Pennsylvania Hospital, in September, 1855; he had been sitting upon a 



1859.] Packard, Affections of the Spinal Column. 



63 



log, beneath a staging upon which there were a good many people, when 
the staging gave way. His spinal column had thus been subjected to great 
force at each extremity. When brought to the hospital, he was much col- 
lapsed, and suffering extreme pain ; his back presented a striking prominence 
at about the eleventh dorsal vertebra. The pain extended all around his 
body; neither the sensibility nor the motions of his lower limbs were im- 
paired. He was laid in bed upon his right side ; reaction having occurred, 
counter-irritation and diaphoretics were employed, and his bladder emptied 
once by means of a catheter. No bad symptom ensued ; a week after his 
accident, he was able to stand up, holding by a chair ; and he gradually 
gained strength, although the deformity of his back remained. At the end 
of six weeks he was well enough to be discharged. 

Now, what was the lesion in this case ? The eleventh dorsal vertebra 
formed a very marked projection backwards ; or, to speak more correctly, 
the spinous process of that bone constituted the apex of the angle made 
between the upper and lower portions of the vertebral column. There could 
not have been any great degree of compression of the cord, without some 
symptoms ; but such compression would seem inevitable, if luxation had 
been present. Nor is it at all certain that luxation can occur in any but 
the cervical vertebrog ; no instance is recorded in proof of such a possibility. 

The supposition of a fracture was excluded by the impossibility of lessen- 
ing the angular bending of the spine, by the want of crepitus, and by the 
rapid recovery ; and besides, had such deformity been the result of fracture, 
injury to the cord would most certainly have been sustained. 

Sir AsTLEY Cooper relates a very similar case to the above, except that 
in it there were two or three spinous processes broken also, and a laceration 
of the muscles on one side ; complete recovery ensued. 

It was suggested by a gentleman who saw the case of which I have given 
the details, that the injury was neither a fracture nor a luxation, but a 
squeezing out forwards of the inter-vertebral substance, the mechanism being 
the same as when the body of a vertebra is crushed by indirect violence. 
The inter-vertebral fibro-cartilage is held in place by very close and strong 
attachments to the bones above and below; it is, moreover, confined on 
every side by the ligaments, and especially in front by that one which 
usually receives the name of anterior common ligament ; so that such a 
displacement of it would seem almost impossible practically. This expla- 
nation must, therefore, be looked upon as purely theoretical, until an 
opportunity occurs for verifying it by dissection. 

Two cases of somewhat similar deformity have come under my notice, 
although, as will be seen, their attendant circumstances were different ; I 
call them similar, because they likewise concerned the eleventh dorsal ver- 
tebra, which was abnormally prominent, and because the precise nature of 
the lesion could not be detected. In one of them, the child was a stout 
and healthy girl, 4 years of age ; five or six weeks previously to my seeing 



64 Packard, Affections of tlie Spinal Column. [Jan. 

her, she was known to have fallen down some steps. When her mother 
brought her to me, she told me that she had noticed, a few days before, 
something peculiar in her walk, and was led to examine her, when she 
found a lump in her back. This lump proved to be the spine of the 
eleventh dorsal vertebra, projecting very slightly to the left, and maintain- 
ing perfectly its relation to the transverse processes and to the ribs ; as if 
the lower part of the spinal column had been displaced forward en totalite. 
The child walked quite feebly, and carried its shoulders a good deal back- 
ward. No effect had been produced upon the bladder or rectum. Unfor- 
tunately, this very interesting case has passed beyond my reach. 

The other case was that of a girl 3|- years old, not at all healthy in 
appearance, and of small stature. About a year before she was brought to 
me, &he had a very serious illness of some kind, and never perfectly recovered 
from it ; at about the same time she fell down some stairs, and to this fall 
her mother seemed disposed to attribute the affection of her spine. She 
began to be quite lame about six months afterwards. Upon examination, 
three months ago, the eleventh dorsal vertebra was seen to project back- 
v/ard to a marked degree, much as in the preceding case ; and this child, 
like the other, walked feebly, and carried its shoulders a good deal back. 
There was, however, some difficulty in urination in this case, and the right 
lower extremity seemed shortened. An accurate investigation was almost 
impossible, from the extreme fretfulness of the child. A stimulating lini- 
ment was ordered, with tonics, and a simple but nutritious diet ; but, as 
might have been predicted, no change has taken place in regard to the local 
affection. 

Now, in these two children, fracture may be at once excluded from con- 
sideration in making a diagnosis, for obvious reasons. Luxation seems 
equally improbable. Might there have been a displacement, partial or 
complete, of the intervertebral substance, or possibly a destruction of it by 
disease ? And if so, how are we to explain the peculiar deformity, and the 
carrying back of the shoulders ? The recent date of the first case, and the 
robust health of the child, excluded from my mind the idea of disease of 
the bones or fibro-cartilages ; while in neither was there the tenderness on 
pressure, to say nothing of the symptoms connected with the spinal mar- 
row, which usually accompany such affections. 

To explain the cases now related, it seems to me that we must assume 
the possibility of some as yet undescribed lesion of the vertebral column ; 
that neither luxation, sub-luxation, nor fracture could have existed without 
symptoms quite different in degree, if not in kind. The exact nature of 
this lesion will probably remain obscure until an opportunity occurs for 
studying it by dissection. 

In regard to the pathology of the spinal cord, although authors have 
given very positive data as to the effects of injuries sustained at different 



1859.] 



Packard, Affections of the Spinal Column. 



65 



parts of its extent, and although much has been written upon its diseases, 
there are still points which have hitherto escaped attention. 

Thus, in fractures of the cervical vertebrae, a very remarkable phenome- 
non is sometimes observable, viz : an intensely pungent heat of the entire 
surface below the seat of the injury. An instance of this is related in 
Morgan's First Frinciples of Surgery, as having occurred at St. George's 
Hospital, London. The temperature of the skin was 111°, while the respi- 
rations were only five or six in the minute. 

DupuYTREN mentions in connection with one of his cases, that the skin 
was hot ; but he seems to mean m.erely the heat of a febrile movement, 
which is but slight compared with the phenomenon now under considera- 
tion. Two cases have fallen under my notice, in which it was present in a 
very striking degree ; in one particularly, that of a man who was struck 
upon the back of the neck by a bale of cotton, weighing two hundred 
pounds, and falling from a height of four stories, the sensation of heat 
communicated to the hand was actually painful. Unfortunately, it was not 
in my power to follow up this patient, who died in about a week from the 
time of his accident. 

How are we to explain this circumstance ? Nothing is easier than to 
say that the rise of temperature is due to deranged innervation ; but in 
what does the derangement consist, and why should the result be a rise, 
and not a fall, of temperature ? It would seem as if a check were removed 
from some heat-generating agent — possibly the sympathetic system of 
nerves — which, no longer controlled by the regulating influence of the 
cerebro-spinal axis, carries on its functions to an inordinate and excessive 
degree. A rise of temperature similar, and perhaps equal to this, takes 
place in some fevers, in which the nervous system is very evidently one of 
the chief seats of the disordered action ; but we have then another obvious 
reason for its occurrence, in the rapidity of the chemical changes which are 
going on. That this latter is at least not the sole cause of the abnormal 
heat in injuries of the cervical portion of the spinal marrow, is evident from 
the fact that respiration is so much diminished in frequency in these cases. 
Whether the same phenomenon is present when the dorsal or lumbar 
vertebrae are the ones involved, I am unable to say, but I am inclined to 
believe that it is not. 

Paraplegia, as is well known, often exists when it is impossible to 
account for it ; but in such cases its onset is generally slow and insidious. 
This rule does not, however, always hold good ; sometimes the loss of 
power is almost instantaneous. A singular case of this kind occurred in 
the Pennsylvania Hospital about two years ago. The patient was a 
remarkably stout seaman, 22 years of age. He said that two months before 
his admission he had been a good deal exposed to cold and wet, while at 
sea, in painting the vessel ; and that he felt pain and numbness in his limbs 
while engaged in this work. He had had no difficulty of urination ; was 



66 Packard, Affections of tlie Spinal Column, [Jan. 

perfectly comfortable, with a good appetite ; his Lowels were regular. The 
reflex action of his lower limbs seemed entirely set aside, and their sensi- 
bility was greatly impaired ; sometimes his feet would become quite blue 
from the languid circulation in their vessels. He could just manage to 
walk, with great difficulty and uncertainty, holding by chairs, beds, or what- 
ever he could grasp. Yarious plans of treatment were successively adopted 
— iodide of potassium, oil of turpentine, very active counter-irritation, 
tonics, strychnia, mercurials — but after many months of alternate improve- 
ments and relapses, he at last left the hospital in a condition very little 
better than when he entered it. 

In another case, that of a little girl, set. 13, at present under my charge, 
the affection seems to be possibly of a rheumatic origin. The child had 
had several attacks of rheumatism, and was under my charge for paraplegia, 
in the fall of 185t. After several other plans had been tried, she recovered 
the power of walking, while using a mixture containing phosphate of iron, 
in conjunction with powerful counter-irritation by means of moxas applied 
over the spine. I say while using, because it cannot be positively asserted 
that the improvement in her condition was altogether due to the remedies 
employed. Shortly afterwards she had a very severe attack of rheumatism, 
involving both the upper and lower extremities, and the pericardium ; but 
after a hard struggle, she shook off this affection also. In September last, 
the paraplegia returned, and she is now in much the same state as when I 
first saw her. Her condition is in other respects good ; she is fat and 
plump, has generally a good appetite and digestion, and sleeps well. She 
has not now, nor has she ever had, any difficulty either in passing or in 
holding her water ; her bowels are very often constipated. There is some 
tenderness over the dorsal and lumbar spines, and some pain there, according 
to her account, all the time. Her lower extremities are entirely powerless, 
and destitute of sensibility; no reflex action occurs when the soles of her 
feet are tickled. No effect seems as yet to have followed from the treat- 
ment, which has consisted in the phosphate of iron, strychnia ( gr. t. d.), 
and moxas to the back. 

Now it is by no means difficult to conceive of rheumatism attacking the 
fibrous envelop of the spinal cord; but in this child's case the parts affected 
in the marked accessions of the disorder are the extremities ; and as yet 
the hips have been exempt. Here is certainly something curious ; a child 
occasionally losing all power and sensibility in her lower limbs, without 
any apparent cause, and liable also to very violent attacks of rheumatism. 
Can we assume any connection between the two ? And if so, why is it that 
pain is so insignificant a symptom in the former, and so excruciatingly 
severe in the latter ? Why is it, moreover, that the two conditions come 
on at different times — yield to different remedies — and disappear independ- 
ently of one another ? 

A gentleman, about 30 years of age, a lawyer by profession, had just 



1859.] Woodward, Anatomical Diagnosis of Cancer. 6t 

come lio]ne from a summer trip, the last two weeks of wliich he had spent 
at the sea-shore, when he consulted me on account of extreme languor and 
debility, affecting especially his lower limbs. He had not taken cold, nor 
been fatigued in any way; nor could he assign any reason whatever for his 
disorder. His liver being somewhat torpid, I gave him a blue pill ; and 
then put him upon the use of tr. ferri chlor. and quinise sulph. This 
seemed to benefit him slightly; but although his digestion was good, his 
bowels regular, and his urine normal, he still complained of excessive 
weakness, particularly in his lower extremities, and of numbness almost 
amounting to pain, in his knees. I, therefore, ordered him of a grain 
of strychnia, thrice daily. As soon as he began to take this, his condition 
improved, until he became strong enough for horseback exercise ; he then 
gradually left off the medicine, and has had no return of the complaint. 
He told me that on days when he expected to go into court, he had to 
omit the morning dose of strychnia, because if he took it, he could not 
control the starting and twitching of his legs. 

I have reported these cases because they seem to me to present some 
points of peculiarity, and because they belong to a class of alfections which 
are as yet obscure, although of great importance ; involving, as they often 
do, the lifelong discomfort and even misery of the patient, and a world of 
annoyance and discouragement to the surgeon. 



Art. yi. — Remarks on the Anatomical Diagnosis of Cancer. By J. J. 
Woodward, M. D., of Philadelphia. (Read before the Biological De- 
partment of the Academy of Natural Sciences of Philadelphia, Nov. 15, 
1858.) 

What is the boundary between the so-called benignant and malignant 
growths ? How shall we define cancer ? To answer these questions cor- 
rectly is of great importance at the present time, since they form the basis 
of all further knowledge of a fatal and imperfectly understood class of ma- 
ladies. The attempt to offer a scientific solution becomes the more import- 
ant since, to put ourselves in a condition to do so rationally, it is necessary 
to go profoundly into a complete investigation of the anatomical character- 
istics of all pathological neophytes. 

We are accustomed to regard cancer as incurable, or if we look forward 
to a time when our therapeutical measures shall be more successful, it is 
from some newly discovered remedy, or some novel combination of agents, 
that we expect a cure. The majority of physicians are apt to regard the 
years of study and patience which too few are willing to devote to investi- 
gations into the minute structure of abnormal tissues as quite thrown away. 



68 "Woodward, Anatomical Diagnosis of Cancer. [Jan. 

They regard tlie succinct statement of detailed facts with which the prac- 
tised microscopist presents them, as of much interest in a general way, and 
possibly as of some value in diagnosis, but turning with a sigh of relief 
from such subtleties, they exclaim, "Give us something pi^acfical.^^ 

But it is from exact modes of investigation, undertaken often simply 
from the love of truth, that the practical ever takes its birth, and should 
careful study enable us at some future time to fix definitely the boundary 
between innocent and malignant growths — should exact observations enable 
us to recognize the conditions essential to the development of either, there 
is every probability that we shall require little ingenuity to enable us, by 
interfering with the essential conditions, to prevent the further increase of 
the new formation. 

It is often asked, Can cancer be diagnosed positively by means of the 
microscope alone ? In other words, if we present a microscopist with a 
morsel of some growth, and without telling him anything of its general 
appearance or of the clinical history of the case, expect him to answer 
categorically the question, Is this cancer or not ? Are we likely to receive, 
and is he justified in giving a direct reply ? 

Our answer to such a query will depend upon our idea of the structural 
characters of cancer. Those who believe that the elementary forms of can- 
cerous growths are specific and invariable, must unhesitatingly reply in the 
affirmative. And hence such microscopists as have believed in a special 
cancer-cell have attempted to diagnose morbid growths in the manner men- 
tioned. The results have been variable ; growths have often been pro- 
nounced cancerous, which have failed to return after extirpation ; while 
others have been considered innocent which have returned a few months 
after the operation with fatal effect. As these unfortunate failures in diag- 
nosis have occurred to some of the best microscopists in the world, the 
microscopic diagnosis of morbid structures has lost the confidence of many 
respectable and well-meaning practitioners. 

Yet a thorough acquaintance with the history of pathological histology 
will show satisfactorily that these failures were not due to the imperfection 
of the instruments employed, or to their inapplicability to the subject, but 
were the necessary result of the stand-point from which the observer re- 
garded cancer. 

The fandamental error from which all others flowed was the notion that 
cancer was a heterologous formation ; that it was, as it were, a foreign 
organism, a parasite on the economy, developing itself at the expense of 
the victim. This idea, prominently insisted on by Lobstein, originating at 
a time when nothing was known of minute structure, and when external 
appearances were all in all, has survived even to the present time, and is 
still taught in most of the text-books and in the majority of the schools. 

True, Johanes Miiller long ago had flung out the broad proposition, 
since largely developed by Virchow, Carl Wedl, and others, that there is 



1859.] 



Woodward, Anatomical Diagnosis of Cancer, 



69 



no heterologous growth, but that every neophyte is a repetition, or 
attempted repetition, of some normal, and especially of some embryonic 
structure ; but this idea was not at first favourably received, and although 
of late it has gained ground with philosophic investigators, yet even at the 
present moment it is far from being generally believed. 

Looking upon cancer as a heterologous structure, diverse totally from 
any normal tissue, nothing was more natural than that those wdio first 
applied the microscope to its study should have expected to find some spe- 
cial elementary form which should be definitely characteristic, just as there 
are special elementary forms belonging to muscular tissue, adipose tissue, 
white fibrous tissue or bone. Accordingly, when the growth was found to 
be made up in part at least of nucleated cells, these were regarded as cha- 
racteristic ; and as a peculiar cell of spindle shape with a large nucleus, 
since famous as the caudate cell, was observed in several of the cancers first 
studied, the idea wtiS promulgated that the caudate cell was diagnostic, and 
cancer was defined as a growth made up in great part of caudate cells. 

Now, it is to be especially observed that although this idea w^as erro- 
neous and led to error, yet that the error was the fault of the interpreters 
and not of the microscope ; for when numerous mistakes in diagnosis had 
shown that growths containing caudate cells frequently ran the course of 
innocent tumours, while many in which no caudate cells existed presented the 
clinical history of cancer, new investigations were undertaken, and a broader 
survey of normal and pathological structures revealed that the supposed spe- 
cific caudate cell was in fact simply a young connective tissue cell, identical 
with that of the gelatinous connective tissue of the embryo, identical also 
with the lymph-cell in a state of transition into fibres, and that although 
caudate cells frequently occur in cancers, just as do also bundles of white 
fibrous tissue, the perfected result of the development of such cells, yet they 
can no more be regarded as characteristic than bloodvessels, which also, 
and far more invariably, enter into the composition of the cancerous mass. 

It is also to be observed that this error of the microscopists thus shown 
to have arisen from generalizing upon too limited a number of facts, was 
the means of leading to important results ; especially it acquainted patho- 
logists with a class of neophytes best described perhaps by the term of 
pathological growths of "unripe fibrous tissue," which formerly had been 
confounded with carcinomatous disease, or referred indefinitely to the vague 
group of sarcoma. 

It was shown, in fact, that the cancerous parenchyma was held together 
and contained iu an areolar framework of fibrous tissue, sometimes ripe, 
sometimes unripe. The unripe fibre-cells of an undeveloped framework or 
stroma were the caudate cells. 

But the idea of a special cancer-cell was not therefore abandoned. It 
was observed that in many cancers the parenchyma or pulp which lay in 
the areola just described was composed chiefly of cells, and as these, in 



to Woodward, Anatomical Diagnosis of Cancer. [Jan. 

very many cases, were large and granular, oval, oblong, or various in 
shape, with one or two overgrown nuclei and large nucleoli, these charac- 
ters were assigned to the cancer-cell. 

At a later date, when it was found that cells were to be observed else- 
where, as occasionally on the ocular conjunctiva, in the tubuli uriniferi in 
Bright's disease, and sometimes in the flabby and overgrown granulations 
of old ulcers, which imitated exactly any one form selected as typical, the 
characters supposed to distinguish the cancer-cell were yet further modified, 
and it was asserted that it was not so much by the appearance of one cell 
as by the conjoined characters of a group of many cells that a diagnosis 
was to be made. Reliance was especially to be placed on the great and 
apparently purposeless variety in the form of the cells to be observed in 
any given specimen, on the large size of the nuclei, on the presence of two 
or more nuclei in one cell, or of two or more nucleoli in one nucleus ; on 
the transparency of the nucleus immediately after the growth is removed, 
and its becoming granular in the course of a few hours, etc. etc. 

There can be no doubt that all these characters exist in many cases in 
the cells of cancer, but if we regard them as pathognomonic, wherein shall 
we see the cancerous nature of such growths, undoubtedly cancerous from 
their history, as I described in two former numbers of this journal,- in which 
no cells existed, the growth having had its development arrested at the 
nuclear stage ? 

It is thus seen that the essential error which lay at the base of all others 
was the idea of the heterologous character of cancer, and the consequent 
notion that there must exist some heterologous form element, the index, as 
it were, of the heterologous nature of the growth, which should serve for 
its diagnosis. 

The progress of microscopic investigation, however, has more and more 
confirmed the notion, which originated in the scientific mind of Johanes 
Miiller. The careful and minute study of morbid epigeneses, more and 
more assures us, that disease introduces no new element into the economy ; 
that when a modified exudation takes place in sufficient abundance to serve 
as the blastema of a new growth, organization takes place, according to 
the invariable laws which guided the original development of the organism, 
and not according to any new laws devised for the exigency. The careful 
micrologist, who studies disease, is more and more disposed to speak less 
of pathological laws than to see in pathological law the invariable, con- 
stant physiological law working out its inevitable results under new 
conditions. 

A severe survey of pathological neophytes assures us that as a general 
rule, they imitate more or less closely some normal tissue. There can be 
no doubt of this in many neophytes. Adipose tumours, fibrous tumours, 
epithelial tumours, and a host of other products of disease furnish examples. 
I know that high authorities have spoken of such resemblances as acci- 



1859.] 



Woodward, Anatomical Diagnosis of Cancer. 



tl 



dental ; but this is, to say the least, unscientific. There are no accidents 
in nature ; all phenomena, even those that seem most erratic, are governed 
by law. 

It surprised none who had duly appreciated this fact, to learn that 
pathological tissues did not spring at once into existence in full perfection, 
but that in their development they passed through a series of stages ex- 
actly similar to the embryonic history of the imitated tissue; that the new tis- 
sue was in fact produced by just the same processes as was that it resembled. 

Nor was it astonishing to find that the development of the growth might 
be arrested at any stage ; just as in the development of the embryo, inter- 
fering causes may check partly or completely the several processes. 

Moreover, the announcement of the law of analogous formation, scientifi- 
cally worked out by Yogel, and which may be thus expressed, that the new 
groivth is prone to imitate preferably those tissues in connection with 
which it occurs, could create no wonderment in minds which had appre- 
ciated the physiological phenomena of nutrition. 

But even after these generalizations had been fully received, many yet 
regarded tubercle and cancer as exceptions : others were homologous, 
these heterologous growths. 

With regard to cancer, with which alone I concern myself in this place, 
a movement in the right direction was made by Yirchow, in 1856. In an 
admirable paper, which must ever command respect, he proclaims his assent 
to the doctrine of Miiller, and attempts to determine the homology of can- 
cer. Carl Wedl has followed in the same path, though with different results, 
approximating nearer in fact to the truth. But in America the vast ma- 
jority of medical men are unacquainted with these investigations, and still 
adhere to the notion of the heterologous nature of carcinomatous growths. 

In view of these things, I ventured to propose, Oct. 18, 1858, in the 
biological department of the Academy of Natural Sciences of Phila., the 
following questions for investigation : — 

1. What special structural characteristics (in the local growth) accom- 
pany the constitutional symptoms of cancer ; and if any, can such struc- 
tural characteristic exist without the constitutional symptoms? 

2. Can cancerous growths properly be termed heterologous ; or, if not, 
with what tissue are they homologous ? 

Having been requested by the department to conduct the investigation of 
this subject, I take this opportunity of desiring gentlemen engaged in simi- 
lar investigations to address me at the University of Pennsylvania, for the 
purpose of comparing results and exchanging specimens. 

Engaged for some time in the investigation of the subject, I am far from 
prepared to publish detailed accounts of my researches ; and furnish this 
paper simply as the first instalment of the labour I have undertaken for 
the biological department. Its object is rather to break the ground and 
begin to sow the seed, than to attempt prematurely to reap the harvest. 



72 Woodward, Anatomical Diagnosis of Cancer. [Jan. 

The idea of the homologies of cancer promulgated by Yirchow may- 
be stated as follows : The areolar stroma or framework in the meshes 
of which the parenchyma of the growth is contained, consists in fact of 
connective tissue, in diverse states of development in different growths : in 
some it is ripe, in others unripe. The parenchyma itself (krebssaft), is 
composed of large nucleated cells figured by Yirchow, much as they have 
been figured by other observers, and which are considered by him as homo- 
logous with epithelial cells. There is no doubt that there are many gross 
external characters by which this idea is justified, and there can be no dis- 
pute as to the fact that in many cancers connected with epithelial surfaces, 
the law of analogous formation induces a far greater resemblance, so as to 
justify the designation epithelial cancer, applied to such growths. But in 
determining the homologies of any given pathological new formation we 
must jealously watch lest we be led away by mere external resemblances, 
and thus induced to misconceive the essential facts of the case. At any 
rate Yirchow's researches led in the right direction, and the sanction of 
such a name as his gave great encouragement to those observers who had 
begun to consider the designation heterologous applied to neophytes un- 
scientific. 

Carl Wedl afterwards, in a laborious treatise, entitled Rudiments of 
Pathological Histology, modified much, and it appears to me for the better, 
the doctrine of Yirchow. The essential diversity between Wedl and Yir- 
chow is that the former regards the large nucleated cells of the parenchyma 
as also homologous with young connective tissue, while the latter considers 
them homologous with epithelial cells. Wedl accounts for the apparent 
diversity between the young connective tissue-cell and the so-called cancer- 
cell, by supposing that in consequence of the very nature of cancerous de- 
velopment the young connective tissue elements, suffer certain pathological 
changes to which all cells are in fact liable, thes6 changes being chiefly 
three, viz : 1. Arrest of development. 2. Hypertrophy, distension per- 
haps would be a better word, in consequence of excessive imbibition of 
plasma. 3. Simultaneous fatty degeneration in consequence of the im- 
poverished quality of the plasma. Cancer then, according to Carl Wedl, 
is essentially, as he himself expresses it, in a passage quoted by me in a 
former paper, "a malformed (aborted) and degenerating new formation of 
connective tissue." {Path. Hist., p. 610.) 

It is not my purpose in this article to enter into an elaborate discussion 
of the homologies of cancer. Although this subject constitutes an import- 
ant part of the duty assigned me by the department, it is my purpose to 
wait until I shall have collected more abundant material than is at present 
in my possession before entering upon it at large. My present object is 
rather to trace out the inevitable consequences of the establishment of Carl 
Wedl's doctrine in connection with the question of microscopic diagnosis, 



1859.] Woodward, Anatomical Diagnosis of Cancer. T3 

and especially of the microscopic diagnosis betAveen cancer, and the so-called 
benignant new formations. 

Before so doing, I desire succinctly to express the notions to which my 
own study of cancerous growths have led me, because, although I might 
dismiss the matter with the simple statement that in the main I am dis- 
posed to assent to Carl Wedl's doctrines on the subject, yet his work {loc. 
cit.) has been as yet so little read in this country, that such an exposition 
will be absolutely necessary to make my subsequent observations generally 
intelligible. 

If cancer be a heterologous growth, as is commonly asserted, the heter- 
ology must reside essentially, as Wedl indicates, in one of two catagories, 
either, 1st, the secondary arrangement or grouping together of the form 
elements must be unlike the manner in which form elements are grouped 
together in any normal structure, or, 2d, the form elements themselves 
must be essentially diverse from any normal form elements. If, however, 
severe investigation shall reveal that the secondary grouping obeys the 
grand law of secondary grouping in all normal structures, and that the di- 
versity between the form elements and those of some normal element, say 
young connective tissue-cells, resides in unessential and not in essential par- 
ticulars, how shall we predicate heterology of structure ? 

I. Now, first, with regard to the secondary arrangement or grouping 
together of the form elements. Carl Wedl has shown, as indeed has been 
long known and described by Bennett, Yirchow, and others, that the essen- 
tial type of secondary arrangement in cancer is the areolar type, and 
that the papillary or dendritic type is a non-essential modification of this. 
But the areolar type of secondary arrangement is the usual plan in all 
the organs of the body, the only modification being into the papillary plan 
in the case of normal as well as of pathological structures. The mode of 
secondary grouping, in a word, in the case of all normal and of all patho- 
logical structures, is the areolar type, or some non-essential modification of 
it arising from local exigencies. We may also go a step further, and set 
forth that the stroma or framework, built according to the areolar type, in 
which the parenchyma of all tissues, normal or pathological, is situated, 
consists invariably of connective tissue in some stage of development ; 
and that the bloodvessels, and nerves and lymphatics, where these exist, of 
all structures, normal and pathological, are distributed, except in their most 
minute ramifications, in the substance of the stroma, and not in the sub- 
stance of the parenchyma itself. 

The vascular stroma of connective tissue thus constituted forms an im- 
portant part of the human frame. Anatomists speak of its, larger and more 
visible portions under various names — such as fasciae, aponeuroses, sheaths, 
capsules, &c. ; and from many of the descriptions one might overlook the 
fact that there is no real separation between these several portions, but that 
the stroma or framework of the whole body is everywhere continuous, and 



H Woodward, Anatomical Diagnosis of Cancer. [Jan. 

forms a connected and uninterrupted scaffolding, in the freely communi- 
cating areolae of which the several form elements — such as adipose cells, 
muscular fibres, &c. — repose. This arrangement is readily demonstrated 
by studying thin sections of any part of the body with a moderate magni- 
fying power. The shape and size of the areolae vary much in different 
tissues. Thus, for example, the areolae in the muscles are much more 
elongated than those of adipose tissue; and these, again, are far larger 
than the areolae of the cutis verae. But the areolae vary also infinitely in 
shape and size in the same tissue, as is conspicuously seen in the study of 
thin sections. 

The stroma of pathological growths, including cancer, is demonstrated, 
by means of thin sections, to present identical characters, and similar rela- 
tions to the form elements of the parenchyma; and if in the case of cancer 
the large size and variable shape of the areolae be insisted upon, the above 
remarks will indicate that no heterology can be predicated on that ground. 

The stroma of normal structures in the adult consists invariably of bun- 
dles of well-developed connective tissue. In the embryo, however, there 
exists a period for every tissue, in which the stroma is composed of unde- 
veloped connective tissue, of caudate cells, in a word, varying in the 
degree of their development with the age of the embryo. In the case of 
pathological growths, also, it is common to find the stroma consisting of 
embryonic connective tissue elements ; and if, as has been asserted above, 
pathological growths are developed in the same manner and according to 
the same invariable laws as normal textures, we would, a priori, expect 
this to be the case whenever the death of the patient, removal of the 
growth by the surgeon, or any other cause, arrests development in the 
embryonic stages. We cannot, then, predicate a heterologous character of 
a cancer, or any other pathological new formation, because the connective 
tissue of the stroma consists of caudate cells. Such a condition is merely 
an expression of the fact that the development of the growth is in the 
embryonic stage. 

It is also to be observed that there exist in the adult, textures (such as 
the fasciae proper, many capsules, &c.) in which the vast majority of the 
areolaa are empty, or contain only the exuded liquor sanguinis in which all 
the tissues are bathed. Moreover, in certain textures, some of whose areolae 
contain other elements, others are empty. Thus, in the transition ground 
between the skin and the subcutaneous adipose tissue some of the areolae 
are empty, while others lodge fat-cells. If the development of the part is 
completed, the boundaries of such empty areolae consist of fully developed 
connective tissue bundles ; but there has always existed a period for every 
such areola, when attached to the inner margin of its boundaries of con- 
nective tissue bundles were embryonic forms (the caudate cells), in several 
stages of development, the most developed being situated peripherally, and 
the least developed towards the cavity of the areola. At a still earlier 



1859.] Woodward, Anatomical Diagnosis of Cancer. 

period no cavity existed, and the whole areola was filled with embryonic 
connective tissue elements, the least developed occupying the central po- 
sition. 

There is good reason to believe that the history of the development of 
an empty areola, thus chronicled, is the history of the development of those 
areola) which contain other form elements, if we add to what is above writ- 
ten the furtlier statement that the elements last formed in the interior of 
the areola, in virtue of the unexplained force which regulates the develop- 
ment of the organism, develop, not into connective tissue, but into the 
elements of the tissue forming, whatever it may be. A good example, 
which will illustrate my meaning, is the history of the normal development 
of the skin and subcutaneous adipose tissue of the human embryo. At an 
early period the skin and subcutaneous adipose tissue are apparently homo- 
geneous; the one is covered by no epithelium and contains no glands or 
hair-follicles, the other contains no fat-cells; both are alike composed of 
caudate cells in various stages of development into fibre. Examination of 
sections shows that the areolar arrangement above indicated obtains. At 
a later period sections reveal the presence of fat-cells in the subcutaneous 
areolae; certain areolae in the skin are found occupied by little groups of 
cells, which are eventually transformed into glands or into hair-follicles and 
hairs, and an epithelium has made its appearance upon the surface. There 
is every reason to believe that this is, in the main, the history of the de- 
velopment of all normal structures. There can be little doubt that it is 
also the history of the development of all pathological growths. Especially 
interesting, in this connection, is the study of the development of bulky 
inflammatory exudations, and of that interesting class of tumours long 
spoken of vaguely as albuminous sarcoma, which are best described as 
pathological growths of unripe connective tissue. 

If, bearing in mind the above facts, we proceed to the investigation of 
cancer, we are driven to conclude that the term heterologous'^ is in nowise 
justified by the secondary arrangement of carcinomatous growths. It 
only remains, then, to consider the character of the elementary forms of the 
parenchyma. 

II. In studying, secondly, the elements of the parenchyma which are 
contained in the areolas of the cancer stroma, I have been driven from the 
belief that these elements are in truth heterologous ; for although at first 
sight the cells or nuclei which may be present are dissimilar to the elements 
of any normal tissue, yet the dissimilarity is not of essential nature, but 
such that it can be readily accounted for by supposing the cells to have 
been subjected to certain morbid processes which are not peculiar to 
cancer. 

Among the opinions advanced of the homologies of the elements of 
cancer two only deserve notice in this place, that which regards them as 
homologous with epithelial cells, as advanced by Yirchow, and that which 



76 Woodward, Anatomical Diagnosis of Cancer. [Jan. 

regards them as diseased connective tissue elements in the embryonic stage, 
which is the doctrine of Wedl. 

With regard to the first doctrine, it is to be remarked that the shape of 
the normal elementary forms of any texture vary considerably; cartilage 
cells, the cells of the parenchyma of the liver, nerve-cells, &c., may espe- 
cially be quoted in connection with this observation. In mere shape a 
given elementary form of one tissue may more or less resemble the elemen- 
tary forms of another tissue ; yet, the situation and general relation of any 
given series of forms will readily determine their homology. IS'o one, 
for example, will deny the epithelial character of the layer of cells lining 
the small arteries; yet, any microscopist can in a few moments satisfy him- 
self of the correctness of the observation of KoUiker (Micros. Anat., p. 678, 
Phila. edit.), that these cells, when isolated, "present no small resemblance 
on the one hand with the fusiform cells of pathologists," as v,^ell as "with 
the formative cells of the elastic fibres and of connective tissue." It is by 
the situation and obvious purpose of these cells that their epithelial cha- 
racter is determined. 

When we come to apply similar criteria to the cells of the cancer 
parenchyma, we cannot, it appears to me, fail to deny them the epithelial 
character, however single cells may resemble epithelial cells. 

It is the habit of epithelial cells to be placed in a single or several layers 
upon free surfaces. We find them nowhere piled together, filling up com- 
pletely the areola of a connective tissue stroma. If the cells were found 
simply lining the areolae, and these were empty, or simply filled with fluid, 
we might call them epithelial cells ; but now, not so. If they be really 
epithelial cells, there is heterology of grouping, and cancer is a heterologous 
formation. For this reason, alone, I would reject the theory of Yirchow. 
Still more do I reject it, when I find among the flattened forms, upon 
whose external resemblance to epithelial cells Yirchow based his doctrine, 
numerous other elements far more resembling young connective tissue forms, 
and observe no forms which cannot be explained by supposing embryonic 
connective tissue elements to have been more or less modified in consequence 
of the three morbid processes alluded to by Wedl {loc. cit.); and above all, 
when I consider the grouping of the elements, and their relation to the 
stroma. With Wedl, then, I regard cancer to be a malformed new forma- 
tion of connective tissue. In degree of development it corresponds in its 
totality, as a general rule, to connective tissue in the stage in which, as 
above described, all the areolae are filled with embryonic forms, though 
sometimes the areolag, or some of them, are filled only with fluid, giving us 
alveolar cancer ; or if the communications between the several areolae have 
been obstructed, cysts make their appearance. 

The influence of the three morbid processes mentioned by Wedl, in pro- 
ducing the forms observed in cancer, may be thus stated : — 

1. Development is arrested while growth proceeds. The history of the 



1859.] 



Woodward, Anatomical Diagnosis of Cancer. 



11 



development of connective tissue, is that of a series of transitions from round 
to oval, from oval to spindle-shaped elongated cells, with final fibrillation 
of the cell content, and ultimate metamorphosis into the well known bun- 
dles. In the round or oval state these cells are capable of multiplying by 
division. Now, the young connective tissue elements in cancer may have 
their development arrested in any of these stages, and as a general rule it 
may be stated that the more malignant and rapidly developed the cancer, 
the earlier the point at which the development of the single forms is arrested. 
Arrest of development may even occur in the stage of nucleus, before cells 
are formed. Its arrest in the earliest period, after the formation of cellis, 
gives round or oval forms ; a little later (when the cells are preparing to 
multiply by division) it will give double and plural nucleated cells ; a little 
later we will have elongated cells, more or less approaching the caudate 
shape. The arrest, as a general rule, does not affect all the cells alike ; but 
one cell may proceed further in its development than its neighbour, and 
hence arises an infinite variety of forms. 

2. The diversity of form in the elements of the parenchyma which arises 
thus, is still further increased by the fact that growth proceeds, although 
the development of the cells has been arrested. ISTay, from the excess of 
blastema furnished, the cells may overgrow and become hypertrophied, or, 
perhaps, it would be better to say distended, so that they exceed the ordi- 
nary size of connective tissue cells at a like period of development. The 
same thing occurs frequently in the nuclei, and hence the great size of the 
nuclei in the so-called cancer-cells. In consequence of mutual pressure 
among the form elements resisting this endosmotic distension, the form of 
the cells is yet further modified, and a more infinite diversity in the shape 
of the elements results. 

3. Lastly, to complete the picture, the same perverted and impoverished 
character of the blastema, or of the forces organizing it, which determine 
arrest of development, determines also atrophy; fatty degeneration, in a 
word, which, proceeding simultaneously with the growth of the cells, ter- 
minates finally in their destruction, and in that ulceration and sloughing 
which is so characteristic. 

To this cause is due the granular appearance of the cells in cancer, and 
it is to be observed that this character is frequently most conspicuously 
seen in growths which were enlarging rapidly at the time of their removal 
from the body. 

The three processes thus enumerated, acting on young connective tissue- 
cells, are, then, competent to produce all the varieties of form noticeable in 
cancer ; but other facts, besides anything observable in cancer, can be 
brought forward to prove the same thing ; especially significant is the fact 
that in flabby, juicy granulations the connective tissue-cells on the surface, 
which are supplied with an excessive quantity of blastema, while their 
forces are impaired, and their vitality diminished by contact with the atmo- 
No. LXXIII Jan. 1859. 6 



r 



IS Woodward, Anatomicai Diagnosis of Cancer. [Jan. 

sphere, may suffer metamorphoses of a similar kind ; and huge, misshapen 
cells, with distended nuclei, and filled with oil-granules, may result, which, 
viewed by even skilful observers, might be confounded with cancer-cells. A 
similar distension of the cell and nucleus, with degeneration of the contents, 
has been observed in certain epithelia, especially in the case of that of the 
tubuli uriniferi in Bright's disease. The cells, then, present a great resem- 
blance, in mere external characters, to those of cancer. Yirchow used such 
facts to justify his doctrine ; but, properly interpreted, they would lead 
rather to shake amy faith in characters based upon form alone, without 
regard to situation and other relations. 

If it be regarded as an established fact, that the three morbid processes 
named can modify connective tissue elements, so as to cause them to present 
the characters of cancer, the question at once arises, how account for the 
simultaneous occurrence of the three processes in cases of carcinomatous 
disease ? If the view of cancer above presented be correct ; if its homo- 
logies have been rightly understood, the answer to this question will 
complete our knowledge of cancerous growths, and undoubtedly a correct 
determination of the conditions which serve as momenta, will be the basis 
of new and satisfactory therapeutical measures. 

It is not my purpose in this paper to enter into any elaborate discussion 
of these momenta ; indeed, at present there are not enough facts to justify 
it. Suffice that the momenta cannot be of a purely local character ; such 
would fail to account for the return of the disease in internal or other 
organs, both before and after extirpation. Pending their satisfactory deter- 
mination, we may continue to speak of a cancerous cachexia, or modifica- 
tion of the blood, as the starting point, and regard the local processes as 
the inevitable result of the perverted character of the circulating fluid. But 
we must avoid dogmatism on this point ; for many reasons, such a solu- 
tion is far from satisfactory, and it is seldom safe to imagine unproven 
anomalies to account for observed phenomena. 

With this brief statement of the homology of cancer, we are prepared to 
enter into the discussion of the grounds on which its anatomical diagnosis 
is to be based. 

And first, it may be remarked that the initiatory step to be taken in 
attaining data for microscopical diagnosis, is to reject the unscientific notion 
which I have shown to be the natural result of a belief in the heterology of 
cancer ; I mean the notion of a special cancer-cell. 

He who regards the presence of any one characteristic form to be pathog- 
nomonic, may be favoured, fortunately, with some accidental success in 
isolated cases ; but in many instances, he is doomed to inevitable disap- 
pointment. 

It is after a profound investigation of the anatomical characteristics 
of the whole growth, alone, that a diagnosis, based upon microscopic ap- 
pearances, is justifiable. It is not enough to scrape a little juice from the 



1859.] Woodward, Anatomical Diagnosis of Cancer. 79 

surface of a scrap, and to predicate a definite conclusion upon the shape of 
a few cells. The microscopist, whose views permit him to adopt such a 
course, if long experience and great practice have matured his powers of 
observation, will frequently present an opinion upon such data, which will 
coincide, fortunately, with the after history of the case ; but he will as cer- 
tainly commit frequent errors, which will bring discredit upon the microscope 
as a means of clinical investigation. 

I propound, then, the proposition that, to justify the microscopist in his 
diagnosis, the whole growth must be submitted to him ; he must be ena- 
bled to study not only the isolated elementary forms, but their secondary 
arrangement and their relation to each other. Where possible, so much of 
the surrounding tissues should accompany the growth as shall enable him 
to determine minutely the relations of the neophyte to the normal textures, 
and the question of the healthy or diseased character of these. It is also 
essential, for the purpose of facilitating the diagnosis, that he should be 
informed of the seat of the growth ; for although a practised anatomist 
will often determine the organ from which a morsel may be presented to 
him, yet diseased organs so lose their normal characters as to render it 
often difficult, or even impossible, to decide which of two similar organs 
is concerned ; and without due information, it will readily be conceived by 
any one who has read the above paragraphs, a portion of a normal texture 
transformed by disease may be mistaken, even by a practised observer, for 
a new formation, thus giving rise to necessary error in the interpretation. 

I propound the above proposition the more emphatically because many 
practitioners act upon very different ideas. They hand the microscopist 
some pathological morsel, often half putrid from the length of time which 
has elapsed since its removal from the body, or injured by maceration in 
water and alcohol, and even if he be not informed as to the size or seat of 
the growth, they expect him to reply categorically with regard to its nature 
and future history. The microscopist, whose time and inclinations permit 
him to investigate thoroughly such specimens, will occasionally be enabled 
on rational data to arrive at satisfactory conclusions. But he who has not 
courage to refuse any reply, except where his data are in every respect 
satisfactory, must necessarily fall into continual error. 

Nor this alone. As I conceive it, the microscopist, whose time permits, 
has not done his v/hole duty by a morbid growth when he merely decides 
on the question of diagnosis. Were, not the whole growth necessary for 
diagnosis, it should be furnished, to enable the observer to gain the broadest 
views of the minute structure of the given new formation. None of these 
points are so thoroughly understood as to preclude the necessity for further 
study. 

The whole growth having been submitted, must be subjected to careful 
study ; especially is it necessary not only to examine the isolated elements 
obtained by scraping or teasing, but to make and observe thin sections for 



80 Woodward, Anatomical Diagnosis of Cancer, [Jan. 

the purpose of recognizing their secondary arrangement. These data hav- 
ing been exactly ascertained, it will be proper to call the growth a cancer 
whenever they show it evidently to he a new formation of connective tis- 
sue, aborted or deformed by the three anomalies above indicated, viz : (1) 
Arrest of development at diverse stages in the several elements, with (2) 
progress of growth in the elements, amounting even to distension, continu- 
ing after the arrest of development, and accompanied by (3) a simultaneous 
fatty degeneration. 

It would be foreign from the purpose of this article to enumerate the 
infinite variety of external and of microscopical appearances, which can all 
nevertheless be interpreted by reference to the above data. These will be 
found in the several treatises on cancerous diseases. Looseness in the ad- 
hesion between the form elements, permitting them to exude, or scraping 
the cut surface as the so-called cancer juice, diversity in the external cha- 
racters of diverse parts of the growth, and many other characters supposed 
at different periods to be pathognomonic, are, when present, the result of 
the relative degree to which the three essential anomalies have been carried. 

I must also remark that, in my opinion, so far from the abandonment of 
the doctrine of a special cancer-cell invalidating the results of microscopical 
diagnosis, we are now for the first time in a condition to give an opinion 
which shall deserve the name of positive. And we have gained in cer- 
tainty all that has been lost in facility by substituting the result of a tho- 
rough analysis of the growth for the hasty and flippant examinations on 
which microscopical diagnoses were formerly based. 

In answer, then, to the question. Can cancer be positively diagnosed by 
means of the microscope alone ? I answer unhesitatingly it can, in the ma- 
jority of cases, provided the whole growth, with the knowledge of the nor- 
mal texture involved, be submitted to the pathologist. In very many cases, 
a diagnosis can be made by no other means. At the same time, I am dis- 
posed to admit the existence of transition forms, of which, standing as they 
do upon the boundary line, no dogmatic opinion can be given. But the 
microscopist can always answer positively this is cancer, this is not cancer, 
or this is a transition form. 

In this connection, it must be observed that the growth above described 
as cancer generally pursues a definite clinical history. This has been fre- 
quently described, the growth and final ulceration and sloughing of the 
tumour, the implication of neighbouring lymphatic glands and of internal 
organs, the return of the disease after excision, and the fatal termination. 
There can be no doubt that this is the course of the vast majority of cases, 
and in these the microscopic diagnosis becomes the basis of a sound prog- 
nosis. But the question has been propounded. Whether these structural 
characters can exist as a purely local disease ? Analogy is in favour of 
this possibility. We know, for example, that in the case of pus, its forma- 
tion may be on the one liand the inevitable result of a pre-existing constitu- 



1859.] Woodward, Anatoraical Diagnosis of Cancer. 



81 



tional condition, as is seen in the pustules of smallpox ; or, on the other 
hand, it may be a strictly local process, as in the case of a suppurating 
wound. In like manner, it might be supposed that local conditions acting 
upon a new formation of connective tissue might so modify it as to cause 
it to present the cancerous characters ; and that, as Rokitansky has dog- 
matically expressed it, carcinomata may " originate and subsist" as local 
evils. (Rok., Path. AnaL, p. 196, vol. i., Phila. edit.) 

The possibility of this occurrence cannot be denied on theoretical grounds; 
it is one of those questions as to fact which can only be determined by ob- 
servation. There are upon record a number of cases which would indicate 
that this possibility sometimes occurs. But even if we receive all these 
cases unquestioned, their number is extremely small, and the general rule 
will be, to use again the words of Rokitansky (loc. cit.) : " That far more 
commonly, however," such gro\^i;hs "are associated with a dyscrasis." 
But it is exceedingly questionable whether we ought to receive the record 
in every case. If the history above given of the progress of microscopic 
diagnosis (ivJiich alone is reliable) be correct, we shall regard with great 
doubt a diagnosis unjustified by clinical history, which has been made in 
the faulty and unscientific manner practised till so recently. 

For myself, without attempting to contradict on theoretical grounds the 
existence of a "local cancer,^^ or to deny it dogmatically, as some have 
done, I must confess that I have yet to see a growth which, corresponding 
in characters to what I have above described as cancer, has failed to pursue 
the usual clinical history. I cannot at present, therefore, regard this pos- 
sihility as seriously vitiating a careful prognosis. 

In concluding this article, I shall present a brief account of two cases, to 
illustrate the grounds and method of a microscopical diagnosis. 

Case I. The first case to which I would refer is that of a tumour of the 
breast of a woman 43 years of age, removed at the clinic of the University 
of Pennsylvania, October 16, 1858, by Prof. Henry H. Smith. The de- 
tails of the general history of this case will be found in the "Illustrations 
of Hospital Practice," of the Medical and Surgical Reporter for Oct. 29, 
1858. It is not essential to our purpose to present these details in this 
place. The breast at the time of the operation was enlarged to once and 
a half its normal size. It was smooth, regular, hard, and adherent to the 
skin, which, however, was healthy in appearance. There was no retrac- 
tion of the nipple. 

After its removal, a section of the growth showed that all parts of the 
gland were alike involved, and the cut surface — which was yellowish-white 
in colour, and exhibited a reticulated fibrous appearance — yielded, when 
scraped with a knife, a thin watery serum, rendered turbid by small parti- 
cles mixed with it, which, though not so homogeneous or cream-like as we 
usually see the so-called cancer juice, might readily be mistaken for it upon 
superficial observation. 

The general history of this tumour, and many points in its external ap- 
pearance, rendered it improbable that it was of a cancerous character. Yet 



82 Woodward, Anatomical Diagnosis of Cancer. [Jan. 

it appears to me that a conscientious microscopist, who believed, as many 
yet clo, that cancer is a heterologous growth, characterized by a special 
cancer-cell, and that the leading feature of this cell is its large, clear, trans- 
parent nucleus, with a granular appearance in the rest of the cell, must 
have been constrained to pronounce the growth cancer, when he found that 
the turbid appearance of the juice scraped from the surface was due to the 
presence of little groups of eight to fifteen cells adhering together by their 
edges, and which, in fact, presented all these characters. Some doubts 
might, perhaps, be excited in his mind by the close adherence of the cells 
together, which is not usual in cancer. It was indeed difficult to obtain an 
isolated cell. But this fact could not influence the conclusions of one 
whose stand-point has led him completely to reject the study of the second- 
ary arrangements of growths as an element in diagnosis. 

A fevY thin sections — some made with Yalentin's knife from the fresh 
growth, others with a scalpel from dried portions, which were afterwards 
soaked out, some with water and others with acetic acid — revealed anato- 
mical conditions which would necessitate a very different conclusion. 

The compressed milk-tubes were seen to be separated from each other to 
a preternatural distance, by connective tissue, well developed for the most 
part, but also presenting many fibre-cells, in various stages of development, 
intermingled with the fully formed bundles. The cells of the epithelium of 
the milk-ducts were observed to be in a state of fatty degeneration, with 
distended nuclei. And it will now at once be understood that the groups 
of eight to fifteen cells adhering together by the edges, so far from being 
cancer-cells, or, indeed, any pathological new formation, luere really 
jjortions of the epithelium of the milk-ducts, modified and degenerated as 
a secondary consequence of the pressure to which they had been subjected 
by the extensive new formation of connective tissue in the substance of the 
areolar tissue of the gland, which constituted the primary or essential 
lesion. 

Such groups of epithelial cells adhering together, are frequently to be 
observed when any epithelium is forcibly detached from the subjacent struc- 
tures. And with regard to the distended nuclei, where causes inducing 
impaired vitality — as indicated by the consequent fatty degeneration — are 
accompanied by an excessive supply of plasma to the cells, distension of the 
nucleus is frequently to be observed. The epithelium of the tubuli uriniferi, 
in Bright's disease, occasionally alfords an example of this. It is probable 
that the distension in such cases is, to a great extent at least, the physical 
consequence of an endosmotic act. 

The lesion in this breast was, therefore, pronounced to be simply a patho- 
logical new formation of connective tissue in the normal connective tissue 
of the gland ; an opinion which, of course, became the basis of a favourable 
prognosis. 



1859.] Woodward, Anatomical Diagnosis of Cancer. 



83 



Case II. The other case I shall mention in this place, derives its chief 
interest from the fact that its cancerous nature could only be safely an- 
nounced on the grounds of the minute structure of the growth. It occurred 
in the private practice of Prof. Henry H. Smith. The patient, aged about 
sixty years, presented, in her left breast, an ulcer the size of a half-dollar, 
which involved the nipple, and had gradually attained its present size 
during a period of about eighteen months. During this period, it had been 
carefully treated, but refused to yield to any of the measures adopted, and 
as the patient suffered much inconvenience from the pressure of her dress 
upon the sore, it was deemed best to dissect out the ulcer, including with 
it the whole induration, which was accordingly done. 

The parts removed Avere submitted to me for study, through the polite- 
ness of Prof. Smith. They constituted a mass about three and a half 
inches long, two and a half broad, and one and three-quarters in thickness, 
and contained the whole mammary gland ; some fibres of the pectoral muscJe 
to which the growth was adherent being upon its back, and its margins being 
composed of the healthy adipose tissue of the surrounding parts. 

In order to appreciate the conditions presented, it will be necessary to 
recur for a moment to the normal appearance of the mammary gland in a 
person of this age. It is well known that, after the menstrual discharge 
ceases, the mammary gland midergoes atrophy, and is finally more or less 
completely replaced by adipose tissue. At the age of the patient in ques- 
tion, we would expect to find that " all the gland vesicles have disappeared, 
and nothing but the more or less persistent lactiferous ducts, with their 
epithelium in a state of fatty degeneration, are to be found in the adipose 
cushion which supplies the place of the glandular tissue." (See Kolliker, 
Mic. Anat.) 

That the involution of the gland had fairly progressed in this case was 
evinced by the condition of the opposite healthy breast, which was even 
more completely atrophied than usual. 

Bearing the above conditions in mind, I proceeded to the investigation 
of the case. On cutting into the growth from behind, I observed that the 
ulcer rested upon a grayish-white, firm mass, extending from the skin to 
the pectoral muscle which it involved, some of the fibres of the pectoral ac- 
tually passing through its posterior part. Everywhere else it was bounded 
by adipose tissue into which it extended itself irregularly in several places. 
When the cut surface was scraped with a scalpel, an abundant, homogeneous 
creamy j'm'ce exuded. This juice presented the following form elements 
when studied with an objective of ^ inch focal length. 

{a.) Large oval free nuclei, with a single or double vesicular nucleolus. 
These nuclei were perfectly transparent when first examined, but be- 
came finely granular shortly after the addition of water. 

(5.) Oblong oval, or variously shaped cells, sometimes exceedingly irregu- 
lar in contour, containing a single nucleus, identical with the free 
nuclei above described, except in the occasional absence of the nu- 
cleolus. These cells were granular, and contained many Ascherso- 
nian vesicles of minute size, indicating the presence of well-marked 
fatty degeneration. 



84 



Fleming, Blood-Stains. 



[Jan. 



(c.) Cells identical with the last, but with two nuclei. 

(d.) Caudate or fibre-cells differing only from those of healthy young 

connective tissue in the rather larger size of the nuclei, 
(e.) Every possible transition between the cells described at d, and those 

described at b. 

(f.) Innumerable fat-globules and granules (larger and smaller Ascher- 
sonian vesicles). 

Numerous thin sections, cut with a Valentin's knife, showed that the 
above elements were contained in a loose stroma of connective tissue, con- 
stituted partly of well developed bundles, but partly also of the forms de- 
scribed above at d. These areolae were large and irregular, and communi- 
cated freely. I failed to find anywhere the slightest trace of lactiferous 
ducts, and must regard the new formation as having completely supplanted, 
or replaced the normal textures, as frequently occurs. The pectoral fibres 
among which portions of the growth were infiltrated, were in a state of 
fatty degeneration. 

If the account of structure here given be compared with the views ex- 
pressed in preceding portions of this paper, it will be perceived that the 
data afforded by this case justify from the anatomical point of view, no 
other name than cancer for the new formation. 

The appearance of the patient, however, is far from what would be ex- 
pected in a case of carcinoma. This, however, will not invalidate the 
diagnosis ; emaciation and impaired general health are frequently absent in 
cancer, until a very short time before the fatal termination. 

The operation was performed for the removal of this ulcer in October, 
1858. It is therefore yet too early to look for a return of the disease. 
Should the patient escape this fate, I shall be justified in believing that I 
have seen one case of local cancer ; that is, a growth with the minute 
structure of cancer without its clinical history. I look forward, therefore, 
with much interest to the issue. 

Numerous other instances might be adduced, but I trust the two above 
given will be sufficient to make my meaning clear. And, I therefore con- 
clude the present paper, hoping that it may be instrumental in securing the 
co-operation of other labourers in the future promotion of the important 
task assigned me by the biological department. 



Art. YII. — Blood-Stains. By Andrew Fleming, M. D., 
of Pittsburg, Pa. 

In the trial of criminal cases, especially where the evidence is of a circum- 
stantial character, it is frequently of the greatest importance to determine 
of what certain spots are composed, in order to fix the guilt or attest the 



1859.] 



Fleming, Blood- Stains. 



85 



innocence of the accused. To this end science has been employed, and fre- 
quently, by the weight of her testimony alone, has acquitted the innocent 
or condemned the guilty. Without any desire to magnify her office, it is a 
high tribute to science to know that she can by her powers aid in fastening 
the guilt on him who, under covert of darkness and in the stillness of the 
night, steals upon his victim while in calm and peaceful slumber, and for 
sordid lucre or revenge commits the crime of murder. This duty naturally 
and properly belongs to the medical man, who possesses a knowledge of 
physiology, chemistry and microscopy, which befits him for the examination 
of organic substances. The vocation of the expert thus employed, who 
stands as an acolyte to justice, is one of honour and high responsibility, 
for by insufficient knowledge or experience he may, by his evidence, form a 
link in the chain of testimony which consigns the innocent to punishment 
or sets free the violator of law. 

To arrive at conclusions fraught with such salutary and terrible conse- 
quences, it is a sacred duty to use every means in our power ; to take ad- 
vantage of every circumstance, however trivial, in order to prove, beyond 
the question of doubt, of what certain colouring matter is composed, which 
has stained clothing, weapons, &c., that may be brought into court, corro- 
borative of crime. Before advancing to the plans and formulae by which 
these ends are to be attained, it would be well to have in the mind the 
character of the substance whose correlative it is proposed to examine. 
The blood is an almost homogeneous fluid, endowed, while under the cata- 
lytic influence of the vessels, with a property closely resembling vitality, 
and bearing the elements out of which the various structures are to be 
developed or sustained, and from which the glands elaborate their special 
secretions. The variety of its numerous attributes indicates the complexity 
of its nature. Owing to its complexity, and the absolute certainty required 
in medico-legal investigation, arises the difficulty of the examination of 
suspicious stains. 

Appearance of Blood-Stains. — The colour of blood-stains depends on 
their age, the material on which they are deposited, the quantity of blood 
effused, and the circumstances of moisture and temperature to which they 
have been subjected. If the substance upon which blood is allowed to fall is 
highly polished — such as metal, porcelain, and varnished wood — the stains, 
which will be dark-brown shining masses, easily removed, present cracks, 
radiating from the centre. Shallow stains upon white or porous substances 
are of a lighter shade when of the same age ; yet, when the clots are large, 
the blood forms for itself a base, upon which the surface presents the same 
appearance as when on a polished substance. It is impossible to know 
the age of blood-stains by their appearance, as it is so much modified by 
various contingencies. The colour is altered by being deposited on sub- 
stances which modify it ; and the presence of blood-stains, when small, upon 
clothing, furniture, &c., cannot in some cases be ascertained by examination 



86 



Fleming, Blood-Stains. 



[Jan. 



witli sunlight. Dr. Ollivier, d' Angers,^ was summoned one evening, in 
March, 1833, to examine without delay certain premises, and furniture 
therein, where it was thought a murder had been committed upon a woman, 
whose body had been found upon the street, and there deposited, it was 
supposed, some days after death. Accompanied by Dr. Pillon, he proceeded 
forthwith to the house, supposing that it would be impossible to discover 
blood-stains by candlelight; but, fortunately, this proved the means of 
their discovery. The furniture, the paper-hangings, which had a pale-blue 
ground, and the chimney-piece, which was painted black, had been carefully 
examined in daylight, without anything peculiar being noticed. On bring- 
ing the candle close to the wall-paper, a large number of small spots, of a 
dirty red colour, the fourth of a line in diameter, were discovered, that by 
day had the appearance of black points, v/hich were confounded with those 
making part of the figures on the paper. By the same means spots were 
found on the furniture, and a large one on the chimney-piece. The next 
day these observations were verified by MM. Lesueur and Barruel, who 
were obliged to resort to artificial light to find the spots. 

I. Chemical Examination of Blood-Stains. 

The chemical properties by which the presence of blood, whether belong- 
ing to man or any other warm-blooded animal, is established, are owing 
chiefly to the reaction of its peculiar colouring matter. In the examination 
of suspicious stains it is well to note their absolute and relative position, 
their form, size, and thickness, and, when upon linen, woollen, or other 
stufi's, to number or designate them in some way as belonging to some par- 
ticular part, especially of clothing, for the position of them is frequently 
corroborative of the manner in which the crime has been committed. It 
is necessary to put a mark on weapons which have been examined, in order 
to again identify them. 

When the stains are upon cloth, a piece is cut out, containing the stain, 
or part of it, to be examined, and suspended by a thread in a test-tube ; 
and if the stain is recent, the red colouring matter will soon be imparted 
to the water, but if it is old, a longer time is required for its solution. If 
porous substances, such as wood, stones, mortar, and bricks, with blood- 
stains upon them, are put into water, the blood is dissolved and carried into 
the depths of the material without giving the colour to water. To over- 
come this difficulty, it is necessary to rasp or reduce them to powder, and 
add to water. Stains upon hard substances, whose size renders it incon- 
venient to dissolve by putting them in water, can be scraped off and then 
dissolved. In all cases, when upon iron or steel, care should be taken, in 
removii)g the stains by water, not to allow the instruments to remain long 
enough for oxidation to commence. 



Archives Gencrales, ii. ser., t. i. p. 431. 



1859.] 



Fleming, Blood-Stains. 



8T 



The cliaracteristics by which blood-stains are distinguished from those 
produced by other substances are the following : — 

1. They are soluble in distilled water, and impart to ily a beautiful red 
colour, more or less intense, as the proportion of the size of the stain and 
water vary; of a very feeble alkaliue reaction, changing the red litmus to 
blue. 

2. When ammonia is added to the aqueous solution, no change takes 
place in the colour, but an alteration from red approaching to brown is 
found, in proportion to the degree of concentration of the ammonia. 

3. When the solution is heated, coagulation takes place ; the bright red 
colour is destroyed, and grayish flocculi are formed. 

4. These flocculi are quickly dissolved by solution of potassa, and the 
liquid assumes a green tint by reflected, and red by transmitted light. The 
dichroism produced in this manner, according to M. Gaultier de Claubry,^ 
is a certain indication of the presence of blood. V/hen the solution is 
very dilute, to produce this phenomenon an advantage will be found in 
using caustic potassa. 

5. Blood-stains are insoluble in alcohol, ether, chloroform, and oils. 

6. Dried blood is slowly soluble in strong sulphuric and muriatic acids, 
forming dark-brown solutions ; it is more rapidly acted upon by nitric acid, 
which dissolves it vdth effervescence. 

A little experience in testing shades and tints of colour, whether of a 
simple or compound kind, soon demonstrates the difficulty in distinguishing 
them with accuracy. To avoid this, M. Boutigny^ has proposed an appli- 
cation of the properties which liquids present in their spheroidal state. 
Having found that when a drop of water is thrown into a capsule heated 
to 171° Cent, and higher, the liquid forms a sphere, which neither touches 
nor moistens the capsule — the temperature of the drop of water is always 
96°. 5 C, upon whatever surface the phenomenon is produced, and the 
evaporation, when the capsule is heated to 200° C, is fifty times slower 
than by ebullition at 100° C. — he applied these principles to blood-stains, 
and takes, for example, a stain having a diameter of 0.001 millimetre, or 
0.0393*7 of an English inch. Next a glass graduate of 0.020 millimetre 
in length, and 0.002 millimetre in diameter inside, is taken, and the stain 
then cut out and introduced into the graduate, at a distance of 0.005 milli- 
metre from the bottom, and, by the aid of a pipette, 0.10 gramme, or 1.54 
English grains, of cool distilled water is poured upon it. When the stain 
is completely discoloured, a flat silver capsule is heated to redness over an 
alcohol lamp, the red liquor is removed by a pipette, and thrown upon the 
capsule by blowing gently at the extremity of the tube. This operation is 
scarcely finished before the liquid has lost its transparency, and acquired a 

* Med. Legale, p. 783. 

2 Annales d'Hygiene pub., 1844, ii. p. 217. 



88 



Fleming, Blood-Stains. 



[Jan. 



grayish-green colour. This liquid is then touched with a glass rod, pre- 
viously dipped in a solution of caustic potassa, and it immediately regains 
its transparency, and presents a colour, sui generis, green by reflection, and 
red by refraction. If the liquid is now touched with a rod which has been 
dipped in hydrochloric acid, it loses its transparency, which it regains by 
the addition of potassa, and thus almost indefinitely, provided from time to 
time a drop is added to preserve the original volume of the liquid. This 
very simple and ingenious method, M. Boutigny says, is equally applicable 
to large quantities of blood. 

Analysis. — Prom the indirect method by which the expert proceeds in 
this kind of investigation, it is easy to discover that the results are fre- 
quently not of so manifest a character as desirable. Chemical analysis is, 
however, the only means in our power to determine the composition of 
suspected stains where putrefaction has taken place, or an attempt has 
been made to wash them out with a reagent of a kind suitable to destroy 
the integrity of anatomical elements of the blood. In order to more easily 
and thoroughly comprehend the analysis of blood stains, it is advisable to 
consider on which of the components of the blood it is founded, and to have 
in the mind the characteristics by which they are recognized. 

Of the great number of constituents of the blood, but five are essentially 
concerned in the chemical examination, viz : Hdematin, Iron, Nitrogen, 
Fibrin, and Albumen. 

Hsematin. — It is owing chiefly to the presence of this substance in the 
blood, that the chemical tests are available. This pigment, discovered by 
Lecanu, and as yet not fully known, gives to the blood its vermilion 
colour, and, circulating in the minute capillaries of the body, tints the sur- 
face with carnation hue. It is contained within the corpuscles, and it is 
not possible to obtain it in precisely the same condition in which it exists 
in the blood. When perfectly pure, it is a pulverulent, amorphous mass, 
of a rich dark-brown colour, and, when prepared by sulphate of soda and 
alcohol, acidulated with sulphuric acid, is insoluble in ether, alcohol, 
v^ater, fatty and volatile oils, but slightly soluble in chloroform. Sulphuric 
and hydrochloric acids do not affect it, and water combined with either of 
these, does not dissolve it. Alkaline solutions readily dissolve ha3matin in 
different proportions. When chlorine is passed over haematin, moistened 
with water, white flocculi are formed, the chlorine combines with it, and 
chloride of haematin is produced. The brilliant colour of perfectly pure 
haematin is instantly destroyed by contact with hypochlorous acid. 

It is essential to know if the characteristics of this pigment, as exhibited 
in blood stains, are susceptible of such modification, by the presence of 
other substances, as to make it impossible to discover them by the ordinary 
methods of procedure. The most important, from the frequent examina- 
tion required of steel and iron weapons, is to know that rust formed on 
these can act in this manner. 



1859.] 



Fleming, Blood-Stains. 



89 



J. L. Lassaigne/ among the earliest contributions to the literature on 
this subject, gives his opinion, based upon experiments made with blood 
stains upon instruments of iron and steel, that the results differ according 
to the circumstances under which they have been placed. When stained 
instruments are put in a dry atmosphere and an elevated temperature — 
conditions favourable to evaporation — the stains are in the form of scales, 
which present no change in the physical properties of blood ; but when in 
a cold and moist atmosphere — the water of the blood combined with that 
of the air — there will be produced a film of rust, in which it will be im- 
possible to find the physical properties of dried blood. 

By experiments made during a period of nearly thirty years, M. Las- 
saigne^ has confirmed these results, and says that this difference is owing 
to the combination of the colouring and albuminous principles of the 
blood with the peroxide of iron formed by contact with air and moisture. 

The discoveries of M. Lassaigne have been fully attested, in a practical 
manner, by Prof. H. Rose, of Berlin,^ in the examination of a knife which 
was supposed to have served to commit a murder. The crime took place 
during the summer in a wheat field, where the knife was found a long time 
afterwards. The blade of it was, by the long-continued exposure on the 
damp ground, so thickly covered wdth rust that the metallic polish was to 
be seen in but a few places. A small quantity being removed by scraping, 
and slightly heated in a test-tube, developed ammonia, which changed 
moistened red litmus paper to blue, but, when heated strongly, gave out 
neither a disagreeable odour nor traces of empyreumatic oil. It was a 
clasp knife, open, likely, in the manner in which it was found, and perhaps 
the rain had washed away all the traces of blood. 

The inside of the handle of the knife was filled with a dark or almost 
black substance, which immediately after its extraction was soft, but soon 
became hard and friable. A small quantity heated in a test-tube behaved 
as dried blood, developed a strong and disagreeable odour, formed an em- 
pyreumatic oil, and from the heated residue, by treating it with carbonate 
of soda, was shown a considerable quantity of Prussian blue. 

When a large quantity of this black substance was treated with cold 
water, it did not impart a red colour to the solution. The digestion was 
continued for a long time, and aided by a gentle heat, but not sufficiently 
high to coagulate a solution of albumen, without change. After filtration, 
a very slight trace of albuminous substance was detected. When this 
black substance, treated with water and caustic potassa, was boiled, the 
solution assumed a greenish colour, the filtered hquor showed the charac- 
teristic dichroism, and acted with reagents exactly as a solution of colour- 
ing matter of the blood with caustic potassa. This solution, digested with 

1 Archives Generales de Med., t. viii. 1825, p. 289. 

2 Annales d'Hjgiene pub., 2me ser. t. v. 1856, p. 206. 

3 Vierteljaliressclirift fiir prak. Pliar., III. B. 2 Heft. s. 209. 



90 



Fleming, Blood-Stains. 



[Jan. 



hydrocliloric acid, dissolved a considerable quantity of oxide of iron, which, 
after super saturation with ammonia, fell in the form of a precipitate. 

The black substance in the handle was, therefore, chiefly composed of 
dried blood and oxide of iron, the latter formed as rust upon the iron 
which lined the sides of the knife. On account of the presence of a large 
quantity of oxide of iron, the dried blood lost one of its chief peculiarities 
— solubility in cold water. By a series of comparative experiments. Prof. 
Kose found that the colouring matter of dried blood is completely precipi- 
tated from its solution by hydrated oxide of iron. 

A proof of the accuracy of these observations was given by a closer in- 
spection of the knife, when a little piece of wood was seen in the inside, 
which was probably placed to prevent the point of the blade from striking 
on the handle. This piece of wood, particularly at the end of it, was 
covered with stains of blood which probably had not come in contact with 
the rust. It was transferred to a test-tube containing water, and, after a 
short time, from the wood, red streaks could be observed falling to the 
bottom, whilst a flocculent, voluminous matter, of a reddish tint, remained 
upon the wood, which became whiter the longer the action of the water 
was continued. The red matter thus obtained proved, by experiment, to 
be identical with that of blood. 

After a long series of experiments. Prof. Rose came to the following 
conclusions : — 

1. When freshly-prepared hydrated oxide of iron is digested for twenty- 
four hours, and at the same time frequently shaken, at a low temperature, 
with a solution of a blood stain, the filtered solution contains no colouring 
matter of blood; whilst, by boiling the residue of the filtration with solu- 
tion of caustic potassa, it is easily detected by the proper reagents. 

2. If, in place of hydrated oxide of iron, calcined oxide of iron is treated 
with a like solution of colouring matter of blood, a considerable quantity 
will be extracted. 

3. Hydrated alumina acts upon blood in precisely the same manner as 
hydrated oxide of iron, but requires a larger proportion for the same quan- 
tity of blood. 

4. The detection of colouring matter of the blood is more difficult when 
it has been allowed to fall upon ground composed of rich garden mould. 
A weak solution of the colouring matter of the blood with earth of this 
kind was allowed to digest for several months, when it was found the 
filtered liquid was colorless, which, evaporated on platina foil, left a slight 
residue containing no trace of blood. This soil, boiled afterwards with 
solution of potassa, gave a dark-coloured solution, which was dark-brown 
after filtration, but, on account of the large quantity of earth taken up by 
the alkali, it did not show the dichroism which is peculiar to a solution of 
blood stains with potassa. The solution of earth with potassa, when satu- 
rated with acids, forms brown precipitates resembling those formed without 



1859.] 



Fleming, Blood-Stains. 



91 



blood. In order to recognize tlie presence of blood in such an alkaline 
solution of earth, it is saturated with an excess of concentrated chlorine 
water, when white flocculi appear as in an alkaline solution of blood, whilst 
in a solution of earth and potassa no such flocculi are seen. If the blood 
is concentrated, which falls on the ground, these difficulties are not found. 

The extended researches of Rose have lately been verified by Dr. G. C. 
Wittstein,' of Munich, who was required to examine several articles of 
clothing, and an axe with its handle, found in the dwelling of a man sup- 
posed to be the murderer of a woman, whose body was found in a forest 
with several wounds on the head and a severe fracture of the skull. The 
axe and handle appeared to have been w^ashed with some care, and but few 
stains were noticeable, which, treated, did not furnish satisfactory results. 
The handle was carefully removed, when it was found, as conjectured, that 
blood had flowed between the wood and iron. The blood, mixed with rust, 
in this situation, was found to be insoluble in water, proving the assertions 
of Lassaigne and R-ose to be correct. 

To avoid error in the examination of blood stains when mixed with rust 
or hydrated oxide of iron, I propose the following formula, and by this 
means, at the same time, add an additional test for blood, based upon the 
property, which YerdeiP has shown heematin possesses, of forming, in its 
alcoholic solution, a lake which is insoluble in a mixture of alcohol and 
water. Scrape off the mixture of rust and blood, add thereto the smallest 
quantity of soda, and, with water, make into a thick paste, which transfer 
to a test-tube containing alcohol; boil for a few minutes, and filter. The 
filtered liquor contains the colouring matter in solution, which, upon the 
addition of quicklime in fine powder, falls in the form of a green precipitate. 
For convenience, the solution maybe divided in two portions, one of which 
can be submitted to the ordinary tests for blood. The specific chemical 
character of the colouring matter of the blood, compared with that of pure 
haematin, varies slightly, owing to the presence of the salts contained in 
the former. 

In the year 1829, M. Morin, of Rouen, was called before a tribunal to 
decide, whether certain red stains found upon clothing were produced by 
human blood, or owing, as pretended by the accused, to fish blood, when 
he asserted that stains produced by the blood of fishes cannot be confounded 
with those made by the blood of mammifera. He founded this extraordi- 
nary assertion on making some experiment upon the blood of the salmon, 
by which he found, that acting upon it with sulphuric acid, and supersatu- 
rating the latter with magnesia, then treating the coagulum thus formed 
with boiling alcohol, the colouring matter was dissolved, whilst that of the 
blood of the mammifera is completely insoluble in that vehicle. 

' Vierteljahr. fiir prak. Pharm., V. B. 3 Heft. s. 382. 
2 Traite de Chemie Anat., t. iii. p. 383. 



92 



Fleming, Blood-Stains. 



[Jan. 



It has been shown that M. Morin fell into a grave error in his research, 
by M. Lecanu,* who not only exposed the mistake but used the same for- 
mula to isolate the haematin of human blood. 

Iron is found in many parts of the body; in several secretions, normal 
and morbid, and in the blood, where it is intimately associated with hsema- 
tin within the walls of the corpuscles. 

Fpon superficial examination it would appear that the iron in the blood 
is in such small proportion that it could not embarrass the chemical analysis 
of blood stains. 

M. Persoz, Prof, of Chemistry at Strasburg, communicated to M. Orfila 
that, in the year 1836, to recognize blood-stains, he had recourse to hypo- 
chlorous acid, which, he said, immediately destroyed all other stains except 
those formed by rust or blood, which become dark brown by contact with 
this acid. After receiving this information, the latter with Mr. Cottereau, 
applied this knowledge practically, and recommended this reagent to MM. 
Magouty and Loust, of Bordeaux, who were charged with the examination 
of stains found on the lining of a vest. During the investigation, these 
gentlemen found that direct stains, or those made by a jet, or by dipping 
cloths in blood, were different in their action from those produced by con- 
tact with a stained body. 

From a great number of experiments made on the action of hypochlor- 
ous acid, prepared after the formula of Balard — by shaking pure chlorine 
gas with binoxide of mercury, moistened with water — upon various sub- 
stances, M. Orfila^ concluded : — 

1. That stains made by a mixture of fat and alkanet, fat and charcoal, 
and madder and oil of poppies, behaved almost in the manner as blood 
stains. 

2. Hypochlorous acid is completely inefScacious to distinguish blood- 
stains from those made by rust, colcothar, and fat, because the latter remain 
after a prolonged action of the acid ; but they disappear, as Persoz has 
shown, by the use of a solution of chloride of tin, while blood-stains were 
unaffected by it. 

3. That hypochlorous acid is altogether incapable of establishing posi- 
tively, that a stain is formed of blood, though it can be employed as an 
accessory means, provided it remains in contact with parts stained, but one 
or two minutes. 

■ Brame, who performed these experiments, thought that the hypochlor- 
ous acid should be perfectly free from perchloride of mercury, as it is easily 
obtained by Williamson's method, by agitating fresh chlorine with peroxide 
of mercury. The same author advises removing the stains with faintly 
alkaline solutions, and then performing the experiments in a test-tube. 

' Annales d'Hygiene pub., t. ix. 1833, p. 226. 
2 Annales d'Hygiene pub., t. xxxiv. 1845, p. 112. 



1859.] 



Fleming, Blood-Stains. 



93 



Buchner states that the presence of mercury does not interfere in the least 
with the reaction of the acid, and that chloride of lime, chloride of soda, 
and an addition of muriatic acid, may also be employed.^ 

I have tried the above experiments with hypochlorous acid made after 
the method of Balard, Williamson, and Pelouze (the last, by passing dry 
chlorine over precipitated red oxide of mercury, when chloride of mercury 
and hypochlorous acid are formed; the latter of great purity and concen- 
tration), and found the results agreed perfectly with those of Orfila, &c. 

Above, I have shown that haematin when exposed to the action of hypo- 
chlorous acid, is completely decolourized, then to what constituent of the 
blood is the reaction of this acid owing, and how can the resemblance of 
its action on blood, colcothar, and rust be accounted for ? To the presence 
of iron. This is easily seen by repeating the following simple experiment 
of Dr. F. F. Runge,^ who has shown that iron can be detected in the most 
minute particle of blood. 

A single drop of blood is received on a linen rag, which is then plunged 
into a solution of chlorinated lime, which contains hypochlorous acid in < 
small quantity; the red colour is soon changed to yellow and afterwards to 
a dark brown. The cloth is now carefully washed with pure water, to re- 
move all traces of lime, and the spot treated with an acid (acetic) solution 
of ferrocyanuret of potassium, when it will be rapidly changed to blue — 
ferrocyanuret of iron. 

To detect the presence of blood by the iron contained therein, when the 
fabric has been washed, Yerghauss'' has devised the following plan, which, 
he says, is capable of doing so, indubitably even with the smallest trace of 
blood. The portion of stained cloth to be examined, is calcined in a pla- 
tina capsule, the cinder treated with pure sulphuric acid, and the extract 
tested for iron. 

Nitrogen. — This substance, with which we are surrounded on all sides, 
exists in the body of animals in a gaseous and solid state. Combined with 
two equivalents of carbon, it forms one of those quasi-simple radicals, 
cyanogen (CgN), which has the property of producing salts. The azotized 
matter of the blood, when submitted to a high temperature, is capable of 
yielding this in a state suitable to form bases. 

C. Wiehr* has taken advantage of this and adopted a method to prove 
blood-stains on coloured stuffs, where the solution, tinged by their colour, 
does not permit the use of reagents ; which consists in the generation of 
cyanide of potassium from the blood-stains on the fabrics. After having 
convinced himself of the absence of wool in the cloth, he calcines a red- 

' Liebig's Annale. American Jonrn. of Pharm., N. S. vol. xiii. p. 319. 

2 Grundrisz der Chem., Th. II. s. 221. 

' Cannstatt's Jahresbericht fur 1845, ler B. s. 116. 

Handbuch der gericlit. Med. von J. L. Caspar. 1857. 
No. LXXIII.— Jan. 18.59, 7 



94 



Fleming, Blood-Stains. 



[Jan. 



coloured, stained piece of the stuff in a porcelain crucible, pulverizes the 
residue, mixes the powder with carbonate of potassa and heats the mixture 
to redness. The mixture is then extracted with water, and to the filtered 
solution, a small quantity of solution of the salts of protoxide and of ses- 
quioxide of iron, is added : a precipitate of undefined colour is produced, 
containing the constructed ferrocyanuret (Eisencyaniir-Cyanid) of iron and 
protoxide and sesquioxide of iron, precipitated by the excess of carbonate 
of potassa used in the process. Dilute sulphuric acid is now added, which 
dissolves the protoxide and sesquioxide of iron, and leaves behind the fer- 
rocyanuret of iron, undissolved, showing now its blue colour. The opera- 
tion is said to be successful, if a piece of the stained stuff is boiled in caustic 
lye ; the liquid evaporated to dryness and the residue treated in the same 
way with the salts of iron and sulphuric acid. 

Dr. Wolffs employed the process, with a successful result, in the exami- 
nation of blood-stains which had remained on linen for a period of twelve 
weeks. 

Fihrin. — This protein body is found in animals in two conditions, solid 
as found in muscle and liquid, and perhaps more natural state, in blood and 
various fluids. When blood is allowed to stand, spontaneous coagulation 
takes place, and soon after, owing to its presence, a mechanical analysis is 
found separating the serum from the solid portion. 

M. P. Denis ^ was the first person to point out some singular properties 
possessed by fibrin and its similarity to albumen and casein. By macera- 
tion in water containing a neutral salt, for instance, nitrate of potassa, for 
twenty -four or forty-eight hours, or even longer, according to the propor- 
tion of the salt, it will be dissolved. The new product resembles serum 
and albumen ; it precipitates bichloride of mercury, and is coagulated by 
heat and alcohol. If this saline solution is diluted with water in large 
quantity, the fibrin will reappear with all its original properties. 

The characteristics of fibrin differ, in some degree, from the different 
sources whence it is derived, and it is held that a difference exists between 
that of venous and arterial blood. When the former is triturated in a 
mortar with times its weight of nitrate of potassa and the mixture is 
left for twenty-four hours at a temperature of 100° — 120°, it becomes ge- 
latinous, slimy, and eventually liquid ; in this condition it exhibits all the 
properties of a solution of albumen, which has been neutralized by acetic 
acid. With arterial fibrin no such liquefaction happens, and even the 
fibrin of venous blood, when long exposed to the air or oxygen gas loses 
the distinction.^ This discriminative quality belonging to fibrin as obtained 
from fresh blood, could scarcely be made to serve any purpose in a question 
as to the origin of blood-stains. 

» Canstatt's Jahr. ber. fur 1853, ler B. s. 15. 

2 Archives Gen. de Med., t. i. 3me ser., 1838, p. 171. 

3 Liebig, Handworterbuch der Chem. I. B. s. 881. 



1859.] 



Fleming, Blood-Stains. 



95 



When a piece of any material stained witli blood to a notable degree, is 
suspended in water, the colouring matter is quickly dissolved, leaving the 
fibrin in the form of a grayish mass, with a slight reddish tinge, but which 
becomes white after continued maceration. This can be removed and sub- 
mitted to microscopical inspection to determine its identity. 

There is one circumstance where it is of the highest importance to be 
able to discover traces of blood, in which M. Morin^ thinks he has succeeded. 
The assassin, in his haste to destroy that which is frequently an essential 
portion of the evidence against him, washes his clothes with boiling water, 
sometimes even with the addition of soap, with a view of hastening the 
disappearance of this indubitable evidence of his crime; whence results the 
fixation of certain matters of the blood on the tissue. M. Morin experi- 
mented with tissues stained with blood, by boiling in water with soap, when 
it was found the stains were duller than before. Their consistence was 
always greater than that of the tissue itself; the washings had not percep- 
tibly dissolved the elements of the blood. After reaction for some time 
with solution of caustic potassa a liquor is obtained, which is precipitated 
white by nitric or pure hydrochloric acid, which indicates the solution of 
one or more of the (protein) matters of the blood. By this alkaline treat- 
ment the stain loses some of its colour, but what, then, is the matter which 
is found in some measure indelibly fixed on the tissue ? To solve this 
question, it is only necessary to put the stained tissue in contact with pure 
hydrochloric acid, which dissolves the matter of the stain, and forms a so- 
lution which, carefully reduced to dryness, furnishes a residue having the 
property of acquiring a very clear blue colour, with ferrocyanide of potas- 
sium, and a blood-red colour, with sulphocyanide of potassium, indicating 
the presence of iron. 

Fibrin has the property of attaching itself to the texture of clothes. 
Sulphuric acid has the property of dissolving textures made of hemp or 
linen without altering the fibrin. If, then, a texture of this sort is sus- 
pected of being stained with blood, it is to be plunged into concentrated 
sulphuric acid, which dissolves the texture and leaves the fibrinous part of 
the blood, presenting a network, where may be distinguished the impressions 
made by the texture on which the blood was fixed.^ 

Albumen. — In an examination based upon the chemical constituents of 
the blood, it is necessary to inspect the character of this substance, which 
is presented in large proportion in the blood, and, like fibrin, variable in 
quantity in different morbid conditions. The presence of albumen in any 
fluid can only be proved by its coagulability with heat and nitric acid, 
because the coagulation by heat can be prevented by numerous substances,- 
both acids and alkalies. 

• From Journ. de Chim. Med. Annual of Sci. Dis., 1855. 
2 Lancet, 1848, vol, ii. p. 18. 



96 



Fleming, Blood-Stains. 



[Jan. 



When blood-stains have been submitted to the action of water, the 
albumen is dissolved, and, with the colouring matter, remains in solution. 
When the solution is heated to 145°, coagulation is seen to take place, 
and, at the same time, decoloration of the red pigment, one of the chief 
distinctions of blood. Erom a number of experiments which I have made 
upon the decoloration by heat, there appears to be some analogy between 
it and the coagulation of albumen. If chloride of zinc, corrosive sublimate, 
tannic and arsenious acids are added to a solution of blood-stains, it is 
changed to a bright-red colour, and, when heat is applied, the decoloration 
takes place as usual; but when those substances which are known to pre- 
vent the coagulation of albumen — such as potassa, soda, lime, baryta, and 
tartaric, acetic, gallic, citric, oxalic, benzoic, and meta-phosphoric acids — 
are added, there is no decoloration produced by heat, and, after boiling 
with these reagents, liquors are obtained of various colours and tints. 
Thus far the analogy is complete ; but when sulphuric acid is added to it, 
coagulation takes place, but no decoloration is found from the application 
of heat. The fact that decoloration of a solution of blood by heat may 
be prevented by the action of various articles, should be remembered by the 
experimentalist, for frequently attempts are made, with different substances, 
to destroy the evidences of guilt, which might render invalid the test (3) 
described above, and produce confusion in the result of the analysis. 

H. Zollikofer^ was a short time ago required to examine whether certain 
reddish-brown stains, which were found upon a knife, a pair of scissors, on 
linen, wood, and on the ground, were owing, in a greater or less degree, to 
the presence of blood. The character of the stains required the employ- 
ment of a very delicate test in order to obtain reliable results, and which 
was not possible but by adopting as the point of departure the method of 
H. Rose. His attention was directed chiefly to two of the principal con- 
stituents of the blood, viz., albumen and hagmatin. By means of his experi- 
ments he found a new and specific reaction of heematin, and he is of opinion 
that by this means he is enabled to generalize the process of H. Rose, 
which, according to him, is the only one which can be advantageously em- 
ployed. 

When it is required to examine stains upon rusted iron, two varieties are 
presented for consideration, according to the circumstances under which 
they have been placed, viz., that where the blood has remained less than a 
month in contact with the rust, and the other where the two substances 
have been mixed for more than a month. 

A. Less than a Month of Contact. — The rust is carefully scraped into a 
small porcelain capsule, and allowed to digest for some minutes in cold or 
slightly warm water. The filtered liquor will then contain the soluble salts 
of the blood, albumen and hajmatin. 



Journal de Phannacie, t. xxviii p, 209. 



1859.] 



Fleming, Blood- Stains. 



97 



1. The solution is now heated to ebullition. According to the proportion 
of hsematin and albumen, a dirty-reddish coagulum or a simple opalescent 
cloud is formed. The liquor being most alkaline, it is necessary to neutral- 
ize it with dilute acetic acid. 

2. When the coagulum is dissolved in caustic potassa, the hsematin 
liquefies in such a manner as to render the solution dichromatic, green by 
transmission, and red by reflection. 

3. By adding chlorine water in excess either to the dichromatic liquor 
or to the simple solution (No. 1), there are formed white flocculi (albumen 
and chloride of haematin), which soon separate to the surface of the liquid. 

The reaction of No. 2 is indicative of h^matin alone ; the others indi- 
cate, at the same time, haematin and albumen. When the quantity of blood 
is very small, the dichromatic appearance is not manifested, even when the 
chlorine water still produces a perceptible precipitate. In such cases, and 
to dispel doubts regarding the reagents of H. Kose, he advises to recur to 
the following consideration, viz: hssmatin is the only substance which 
contains iron, and, according to Mulder, C^HggAZgOgFe. When hsematin 
is dissolved — or, rather, simply suspended — in water, if it be acted on by a 
current of chlorine, it is precipitated in the form of white flocculi, and loses 
its iron, which remains in solution in a state of chloride. It is only neces- 
sary, in order to detect the latter, to use sulphocyanuret of potassium, 
which, as is known, is its most reliable and delicate reagent. In operating 
in this way upon a blood-stain which was only two lines in diameter, this 
chemist has obtained a manifest reaction by the use of sulphocyanuret of 
potassium, although chlorine water gave simply a whitish cloud, hardly 
appreciable, which required several hours to precipitate as distinct flocculi. 

B. More than a Month, of Contact. — When blood remains a long time 
in contact with rust, there is formed, as Rose has shown, a veritable com- 
bination, by which hsematin is rendered insoluble in water. In boiling this 
compound, it is necessary to avoid a large excess of the alkali, because the 
saturation will become more difficult. 

When this method is employed, it is required to discover, in the first 
place, if no soluble salt of iron is contained in the spot to be examined. 
This is easily done by means of sulphocyanuret of potassium, which is 
agitated with a simple aqueous solution of the stain before it is submitted 
to the alterative action of potassa. If this reagent detects the presence of 
iron, two experiments are needed : one which consists in treating the aque- 
ous solution by chlorine, to detect the presence of hsematin and albumen ; 
the other, by treating the spot first with pure caustic potassa, and super- 
saturating the solution with chlorine. The iron, separated from the hsema- 
tin by this means, will be found in the product of filtration. 

To show that a stain contains iron, cyanogen (materials from which it 
can be procured), fibrin, or albumen, gives no positive proof of the presence 



98 



Fleming, Blood-Stains. 



[Jan. 



of blood, since these substances are found in many animal and vegetable 
structures, in various forms and combinations; but to be able to detect 
them is a valuable auxiliary means to confirm chemical analysis. Of the 
various tests and methods for the detection of blood, those which are based 
upon the characteristics which h^matin possesses are alone of specific value, 
and in medico-legal investigation should first occupy the attention of the 
expert. The reaction of h^matin is the same, whether obtained from arte- 
rial or venous blood, and chemistry affords no means of discrimination 
between these two forms of the vital fluid. 

Menstrual blood, in its normal condition, would appear to contain no 
fibrin, as has been proved by Dr. Letheby,^ who had an opportunity of 
examining forty ounces of it in a case of imperforate hymen, and Jul. 
Yogel, who procured it in a state of purity in a case of procidentia uteri.^ 
The instances are frequent in which menstrual fluid possesses all the phy- 
sical properties of blood, and hence they might be confounded. Neverthe- 
less, where a charge of rape or infanticide has been preferred, and blood- 
stains produced as evidence of the deed, which, on examination, were found 
to contain no fibrin, the absence of this important constituent of ordinary 
blood would have some weight in favour of the accused. 

To distinguish Human from Animal Blood. — Several methods have 
been proposed to distinguish, by chemical means, human from animal blood, 
and the blood of one class of animals from that of another. The most 
remarkable of these is the plan elaborated by M. Taddei, of Florence, under 
the name of hsematalloscopy,^ which is as follows : — 

The spots upon weapons, soil, or on furniture, are detached by scraping, 
the product is weighed in a delicate scale, after which the smallest possible 
quantity of distilled water is added, and to this a solution of crystallized 
bicarbonate of soda, containing the same quantity, by weight, of the salt 
as is represented by the weight of the blood. If the liquid has been depo- 
sited upon a fabric, it should be separated by water ; and, to determine the 
quantity of it, it is dried at 60° Cent., the cloth to be cut in strips, after 
which they are macerated in water, or, better, triturated in a mortar with 
water, and on drying them, and weighing again, the exact quantity of 
blood will be found, to which the soda, as before, must be added. 

A fabric of linen or cotton, which contained hardly 28 to 30 centigram. 
(5 to 6 grains) of dried blood, furnished a quantity sufficient to determine 
its nature. 

After having well shaken the blood with the solution of the bicarbonate, 
a solution of the sulphate of copper, in very slight excess, is poured into 
it, and, after ten or twelve hours of repose, the mixture is filtered and 

' Todd and Bowman, Physiol. Anat. and Physiology of Man, Am. ed. p. 848. 

2 Lehmann's Phys. Chemistry, vol. i. p. 631. 

3 Manuel de Med. Leg., p. 795. 



1859.] Fleming, Blood-Stains. 



99 



washed with care. The filtered liquor is bluish, and the product found in 
the filter, which is of an olive-green colour, contains the organic substances 
and the carbonate of copper. The filter is now placed upon bibulous paper, 
and dried in the sun or in a stove, between two porcelain plates or capsules ; 
the product is detached and triturated in a porcelain mortar before desicca- 
tion is completed. M. Taddei designates this product powder of interpo- 
sition. As this powder is exceedingly hygro metric, it is necessary to 
protect it from the moisture of the air. 

When it is required to determine if a certain quantity of blood belong to 
man or a vertebrate animal, it is effected by comparison. Ten grains of 
powder of interposition are accurately weighed, to which are added, in the 
same capsule, fifteen grains of dilute sulphuric acid, formed with equal 
parts of acid at 66^, and of water, a mixture to which the author gives the 
name of acid liquor. The capsule is covered with a glass plate, leaving 
only room at the side for the movement of a glass rod for mixing well the 
acid and the powder. In operating at 25° or 30° Gent., the powder of 
interposition, hardly moistened with the acid, changes to olive-green or 
garnet-red, and from being granular, as it was at first, it now becomes 
homogeneous, tenacious, pulpy, plastic, and very elastic. 

This product, deposited upon a large horizontal sheet of glass, remains 
in the same state for ten or twelve hours, after which it spreads, adheres 
to the surface of the glass, becomes shining, and assumes the bright ap- 
pearance of a melted mass. This appearance is shown upon the lower side 
of the mass, after four or five hours in summer, and longer in winter. The 
whole falls lower and lower, the area extends, becomes ordinarily circular, 
and the substance softens, taking the consistence of an extract. If the con- 
tinuity is destroyed by means of a glass rod, the rent will soon be filled and 
the elevations disappear; by gently applying a metallic seal, or a piece of 
money anointed with oil, the impression is only momentary, and the mass 
soon regains its first form; on touching it with the finger, it adheres 
thereto like honey ; bibulous paper applied with care to the surface, cannot 
be elevated without raising some of it, and insects which fall upon the sub- 
stance remain attached as long as the fresh paste not only can be touched 
with the finger or blotting paper, but till it can be compressed without ad- 
hering. The fluidification increases progressively, the product becomes 
semi-fluid, and, on inclining the pane of glass to from 20° to 40°, it flows 
from 80 to 100 millimetres in three or four hours. All the above pheno- 
mena are manifested in the space of a day and a half, at a temperature 
from 25° to 30° Cent, and the fluidification becomes such that, in the 
space of thirty or forty hours, by inclining the glass to 45°, the mass 
travels 135 to 160 millimetres in a short time; in fine, after three or four 
days, the fluidification is complete. In using a rectangular sheet of glass, 
with a graduated scale upon one of its sides, it is easy to determine the 
degree of fluidity during a certain period of time at a given inclination. 



100 



Fleming, Blood-Stains. 



[Jan. 



If the pane of glass upon which the product has been placed is left hori- 
zontal until the mass be completely liquefied, it retains its opacity, but 
becomes so brilliant, and reflects all objects so well, that one can see, as in 
a mirror, all the points of any body which is presented. If, then the sheet 
of glass is turned vertically, and under it a horizontal one, the mass falls 
on the latter, leaving hardly any trace on the former, so that the objects 
are delineated behind the vertical sheet in the whole course of the product, 
which can be made to flow again in the same manner. When the paste is 
laid on a pane of glass exactly horizontal, after a few days another pheno- 
menon is observed. In the area occupied by the fluid mass, two substances 
are shown ; one solid, granular, whitish, and opaque, the other liquid, dia- 
phanous, of an amber tint, which separates to the periphery, enveloping 
on all sides the opaque substance, and forming a zone of eight to ten mil- 
limetres, with fringed edges. The better to note this effect, the glass 
should be placed before a window. These substances are easily separated 
in the following manner : the tare is taken of a trapezoidal, or, better, a 
hexagonal plate of glass, to which is attached, with a little sealing wax, 
a very fine brass wire ; to this is fixed a piece of filtering paper, cut in a 
hexagon, a little smaller than the plate of glass, which has been weighed ; 
by means of a pipette, some of the acid liquor is allowed to fall upon it — 
in quantity, a little more than what is necessary to cover the paper, but 
still not sufficient to flow beyond — and thereon is sprinkled the powder of 
interposition. Having taken the whole from the scale, the powder is 
mixed with the acid by means of a glass rod, and, after several days, the 
plate of glass is inclined so that the liquid portion flows upon another 
plate of glass, and is spread on a printed sheet, on which the letters can 
be easily read through the liquid. The latter is so transparent, that in 
passing the sun's rays through it, and receiving the image in a camera 
obscura, there will be found a circle of a beautiful colour, red as fire, bor- 
dered by a colourless circle, which is itself surrounded by another obscure 
one. 

On letting some drops of the amber-coloured liquid fall into alcohol at 
78° to 82° Cent., the latter is troubled, and a deposit takes place of numer- 
ous filaments, of an albuminous appearance, ashy-white or slightly gray, 
and the liquid becomes a fawn colour; whence it can be concluded that the 
amber liquor is a combination of acid and hasmatin, with an albuminous 
or protein substance. One is soluble, the other insoluble, in alcohol. 

If some of the liquid is spread upon a plate of glass with the pulp of 
the finger, it adheres like a fatty or oily substance. If, now, this plate is 
put into a tumbler filled with distilled water, so that one of its sides touches 
the bottom and the other the edge, at an inclination of forty-five to fifty 
degrees, lines traced by the finger will be seen, and, the vessel being in re- 
pose, this substance is observed to unite by degrees with the fluid, and form 
a mass composed of layers which fall to the bottom. If, now, the plate is 



1859.] 



Fleming, Blood-Stains. 



101 



withdrawn from the liquid, it is seen uniformly covered with a layer of a 
pearl-white substance, which, rubbed by the finger, unite in small opaque 
filaments of a deep gray colour. The same result is obtained when the ex- 
tremity of a glass tube, filled with the fluidified matter, is plunged into water 
and held vertically in the centre. In placing the latter between the eye and 
the light, from the end of the tube is seen flowing a very fine filament, 
which, on breaking, forms small wreaths, attached one to another, that, fall- 
ing slower and slower, and increasing so much in diameter, they lose their 
colour, and acquire a refrangibility, almost equal to that of water, which 
does not longer allow them to be seen. Then the filament which at first, 
coloured and transparent, occupied the centre of the tube, is opaque, and 
to the wreath have succeeded white flocculi, which rise and fall in the liquid. 
This white thread, which remains for some minutes intact and mobile, like 
the filaments, is formed of albuminous substances of the serum. 

If the paste resulting from a mixture of powder of interposition and 
acid liquor, in the proportion of 1 to 1.5, is allowed to fluidify in the bot- 
tom of a conical vessel, and steam directed over it, or a little hot water 
poured upon it before it is completely liquefied, and allowing the same to 
digest with occasional agitation for some time, the solution operates with- 
out any clots or threads remaining. If sufiicient carbonate of lime, in fine 
powder, to saturate all the acid, is poured into this, and the solution after- 
wards filtered, the liquid presents a very beautiful lilac or blue colour, aris- 
ing from the oxide of copper. By washing the residue upon the filter until 
the liquid be scarcely coloured, and throwing some ammonia upon it, a 
fluid passes through of a deep colour — red by refraction, and greenish-brown 
by reflection. If the phenomenon is observed in a glass vessel, as the am- 
monia evaporates, there is deposited a slight layer of opaque matter on 
the sides of the glass, which, when dried, is of an ashy-gray hue, and dis- 
solves without effervescence in water acidulated with hydrochloric acid. 
When completely dried, it is in the form of a crust, very friable, and of a 
bottle-green colour, and which, detached, looks black, and has a metallic 
lustre. The powder thus obtained is insoluble in alcohol, but is soluble in 
that liquid and water when thereto is added an acid, or, better still, some 
caustic alkali. Reduced to paste with one and a half times its weight of 
acid liquor, it imparts a garnet-red colour, but does not form a coherent 
mass like that formed with the powder of interposition. 

Heat exerts so great an influence upon the fluidification, that the paste 
made with the powder of interposition and the acid liquor, in the propor- 
tion of 4 to 5, and, consequently, hard and dry, becomes not only of a 
soft, shining, and semi-fluid appearance, but is completely liquefied after a 
few days, when kept at a temperature from 35° to 40° Cent. On the con- 
trary, if the paste is made in proportion of 1 to 1.5, when at 15° Cent., 
the mass remains without change, or takes the consistence of an extract 



102 



Fleming, Blood-Stains. 



[Jan. 



Characteristics of the Blood of Animals. 

Ox Blood. — In operating as above described, the plasticity and coher- 
ence are found to be less. The mass which is reduced to clots — elastic, but 
hard and dry, when placed upon a plate of glass, shows no change what- 
ever after thirty hours, either in summer or winter ; preserves its form and 
diameter ; neither assumes the consistence of an extract, nor reflects 
images ; and, after some weeks, loses its shape when the plate of glass is 
inclined, takes a darker colour, and alters in firmness so much that the 
clots become agglutinated, and form masses without consistence, and always 
granular, whence flows a portion of acid liquor. 

Pigeon Blood. — The powder of interposition does not mix with the acid 
liquor so as to form a homogeneous, plastic, and coherent paste ; only a 
mass of hard and tenacious clots is obtained, which, divided and without 
cohesion, after some days — aided by a temperature of 25° or 30° Cent. — 
reunite into a sticky, extractiform, and homogeneous mass. 

Green Lizard Blood. — This is with much more diflSculty detached from 
tissues, than the blood of any other animal ; whence the cause of the almost 
indelibility of the spots by water. The powder of interposition does not 
furnish a coherent and homogeneous mass, but only a pile of clots which do 
not adhere ; at first slightly elastic, they become by degrees moist, flabby, 
and of a deep colour, afterwards take the brightness and appearance of a 
semi-fluid substance, and, when the agglutination increases rapidly — the 
temperature being from 30° to 35° Cent. — the clots are united into one 
brilliant mass, black as pitch, and of an extractiform consistence. 

Tench Blood. — The mass formed with the powder of interposition and 
acid liquor, is formed of small clots without cohesion, which do not form 
a plastic and homogeneous substance. 

In comparing human blood with that of animals of different classes, it is 
observed that with the first the powder of interposition yields a consistent, 
elastic paste of a garnet colour, that softens rapidly and falls like dough in 
process of fermentation, and having become brilliant, extractiform, dark, 
and pitchy, it liquefies like syrup, forming large spots with fringed edges, 
when maintained at a temperature from 30° to 35° C, in a horizontal posi- 
tion ; that this paste divides spontaneously into two parts, one liquid, dia- 
phanous, of an amber colour, flowing like water ; and the other solid, white, 
and opaque. 

Blood is not human when there is formed an elastic, consistent, and 
tenacious paste, reducible by pressure to fragments which do not agglutin- 
ate, neither fluidify by any means, nor furnish two distinct substances, such, 
for instance, as ox blood, as the type of the mammifera. In like manner 
with various other bloods distinct differences are found. In fine, it is hu- 
man blood alone, which, not forming a homogeneous and coherent mass, 
whatsoever the proportion of acid liquor may be, gives only isolated clots. 



1859.] 



Fleming, Blood-Stains. 



103 



not susceptible of forming an emplastic body until several days have 
elapsed. 

To appreciate the degree of fluxility {Jluidifiahilite) M. Taddei uses a 
tube 0.50 millimetre in length, and from 0.006 to 0.008 millimetre in dia- 
meter, closed at one extremity and expanded at the other, like a smoke 
pipe, and curved at an obtuse angle. When the mass introduced remains 
several hours, it becomes soft enough to adhere to the glass ; the tube is 
then inclined at an angle of 45°, the mass then flows insensibly and, by a 
graduated scale divided into 200 parts, the distance travelled, after three 
or four hours, is measured. The different kinds of blood by this means 
are divided in the following manner: — 



The blood of the dog, man, and the rat, are found placed in the same 
category, and to distinguish them it is indispensable to compare exactly 
their degree of fluxility. 

To attain the same end, a process has been shown by M. Casanti, who 
uses as a reagent for the distinction of blood belonging to various animals, 
phosphoric acid at a density of 1.8, in the following manner: The first 
step was to establish a distinction between an animal belonging to the 
mammalia and another vertebrate animal, say a bird. For this purpose, 
both kinds of blood were carefully dried and treated by an excess of phos- 
phoric acid; the mammalian blood became agglutinated, and formed into a 
brilliant, homogeneous, and coherent mass; whilst that of the bird (gallina- 
ceous) did not present these characters at all. As to man and other mam- 
malia, six grains of finely -powdered, dry human blood, were put into a 
glass, and nine grains of phosphoric acid added. The blood, on being agi- 
tated with a glass rod, swelled and softened, turned into a brilliant mass of 
a hepatic colour, and as consistent as a common extract, but glutinous and 
devoid of plasticity. On being pressed with the rod, it yielded without 
dividing, and became more homogeneous; when allowed to stand it became 
hard without losing its lustre. The blood of the horse gave very different 
results. The acid first swelled and softened the powder, but the particles, 
far from forming themselves into a mass, turned into hard and shining 
lumps, which did not adhere to each other, and even broke asunder when 
attempts were made to unite them. The blood of the ox, calf, mule, pig, 
goat, &c., gave the same results as that of the horse. The blood of the 



' Non-fluxible Ruminantia (Ox, deer, &c.). 



Tolerably fluxible . . \ Pacliydermata (Hog). 



f Rodentia (Guinea-pig, rabbit, &c.). 
I Solipedes (Ass, horse). 



Coagulable Blood. 




j Quadrumana (Monkey). 
[ Carnivora (Porcupine, pole-cat), 
p Carnivora (Cat, fox, dog). 



Very fluxible \ Bimana (Man) . 

I Rodentia (Rat). 



104 



Fleming, Blood-Stains. 



[Jan. 



cat formed a single mass like that of the man, but it broke at the slightest 
touch. Human blood always exhibits definite characters, notwithstanding 
differences of age, sex, health, or disease; except, however, as regards cata- 
menial blood, which, although it gathers up into a mass, divides very soon 
into dry and swelled particles, that show no tendency to reunite.* 

A simple means of distinguishing the blood of different animals was 
proposed by Gallicano Bertazzi,^ who based his researches on the behaviour 
of iodine water on the contents (heematin and blood casein) of blood cor- 
puscles. After preparing a saturated solution of iodine in water, he ex- 
perimented in the following manner: A circular piece, five lines in diameter, 
is cut out of the spotted cloth and covered with 20 grains (1.25 gramme) 
water; when the colouring matter is dissolved, the stuff is removed with the 
forceps, pressed out and treated with 10 grains of iodine water. A solution 
of bird's blood prepared in this manner, according to him, will change to 
reddish-brown, be troubled, and yield an abundant precipitate; a solution 
with that of carnivora turns reddish without showing any cloudiness or de- 
posit, whilst with that of the herbivora, it only takes on a colour resem- 
bling Cyprus wine. In order to produce the same effect with the blood of 
carnivora and human blood, 20 and with the herbivora 40 grains of iodine 
water must be added. With the blood of birds and carnivora the precipi- 
tate obtained is reddish-brown, and becomes red in the air, by degrees re- 
sembling cochineal; that of the last (herbivora) at first dark red, becomes 
changed to chestnut brown in the atmosphere. 

By Specific Odour. — For the purpose of discriminating between differ- 
ent kinds of blood, on several occasions recourse has been made to the 
odour evolved by the addition of sulphuric acid. M. Barruel,^ in 1829, 
when trying to obtain some of the colouring matter from ox blood, was 
struck with the peculiar animal odour developed on the addition of sulphuric 
acid to fresh blood, and subsequently in treating human blood in the same 
manner, the smell, resembling human sweat, was so powerful as to drive 
him from the laboratory. This discovery led him to make several experi- 
ments, with the following conclusions: — 

1. That the blood of every animal contains a peculiar odorous principle; 
that of the male strong, of the female like it but more feeble. 

2. This principle is exceedingly volatile, and has a similar and peculiar 
smell of the sweat or vapour of the skin or lungs of the animal under con- 
sideration. 

3. This principle is intimately combined with the blood, and not per- 
ceptible as long as the combination remains, but when this is destroyed the 
odorous principle of the blood evaporates and develops the characteristic 
smell of the animal from which it is derived. 

• Lancet, 1849, vol. i. p. 348. 

2 Annali Univer. di Med. Aprile, 1839. 

^ Annales d'Hjgiene pub., t. i. p. 267. 



1859.] 



Fleming, Blood-Stains. 



105 



4. This development is best obtained by means of sulphuric acid. The 
result is obtained by adding to one part of blood one and a half part (by 
measure) of concentrated sulphuric acid, and stirring the mixture with a 
glass rod. There is an elevation of temperature of the mass, during the 
process, when the peculiar smell is produced. 

The researches elaborated by Barruel were in some degree confirmed by 
Taddei de Gravina,* who experimented with the blood of the ox, cow, and 
very young calf, an old and a very young hare, the goat, sheep, hog, horse, 
and mare, man and woman, and numerous species of birds. From his va- 
rious experiments he arrived at the following results: 1st. That it is true 
that the blood of every vertebrate animal has in it an odoriferous principle, 
identical in all individuals of the same species, and similar to the odour of 
the cutaneous transpirations, or more properly speaking, of that part of it 
which gives to each animal its characteristic smell. 2d. That the notion of 
those who pretend to recognize to which, among a number of individuals of 
the same species, a given portion of blood belongs, is false. 

Carl Schmidt^ made numerous experiments upon the odour of the blood 
of man, the dog, cat, calf, sheep, hog, goat, cat, besides those of hens and 
frogs, together with that of various animals of the different classes. To 
avoid the difficulties in this kind of investigation, the examination took 
place in the presence of six intelligent persons who were requested to com- 
municate their decision. During the trial they detected many kinds of 
blood with great accuracy and agreement, but throughout there was not 
much constancy in their opinions. In fine, that the method of Barruel is, 
under all circumstances, characteristic only with the blood of the goat, 
sheep, and cat, whilst with all the others very doubtful results are given. 

A case occurred in which a man was charged with an assassination, at 
whose house was found a bucking cloth presenting many grayish stains. It 
was required to decide if these spots were owing to human blood, or as the 
prisoner contended, they were produced by meat which he had enveloped in 
the cloth the year before to shield it from the flies. MM. Chevalier and 
Barruel were charged with the examination, and among other tests used 
that by odour. After making a solution of the stains, concentrating it at 
a low temperature, and mixing this with concentrated sulphuric acid, a 
slight odour resembling the smell of mutton was eliminated. While this 
opinion went far to admit the declaration of the accused, these gentlemen 
stated before the tribunal, the difficulty of deciding by this means, and the 
insufficiency of their evidence, requiring the court to rely upon other testi- 
mony for a verdict.^ 

' British and Foreign Med. Review, vol. ii. p. 226. 

2 Die Diagnostik verdachtiger Flecke in Criminalfallen. Mitau und Leipzig, 
1848, s. 19. 

^ Annalea d'Hjgiene pub., t. x. 1833, p. 160. 



106 



Fleming, Blood-Stains. 



[Jan. 



Some few years ago MM. Tardieu, Barruel, and Chevalier, were required 
to decide if blood found in the house of a woman, who was accused of mur- 
der, was human, or, as she said, that of a sheep. The substance in question 
was submitted to the action of sulphuric acid in order to produce the pecu- 
liar odour. The disagreement between these experts was so great as to 
produce complete confusion in their own minds, and to destroy the confi- 
dence which had for a time been reposed in this test.* 

It would be of the greatest value to be able by any means, however dif- 
ficult or tedious, to distinguish the blood of one animal from that of an- 
other. BarrueP himself has admitted that his formula does not afford the 
certainty required in medico-legal investigation, and even for an approxi- 
mation to a satisfactory result a large quantity of fresh blood is needed. 

In the majority of assassinations a great length of time elapses between 
the commission of the deed and the examination of the suspected stains, 
and the quantity of blood presented is exceedingly small. To succeed by 
Barruel's method would require a more exquisitely cultivated sense of smell 
than is possessed by many persons. The difficulties and embarrassments by 
which this formula is surrounded, render it, for almost all ordinary cases, 
nearly useless, and in the few in which it can be employed, it holds a doubt- 
ful position. There have been many experiments performed according to 
the method of Barruel, with different kinds of blood, and the results of the 
observations by Couerbe, Leuret, Budekind, Erhard, Merk, Soubeiran, 
Denis, and Chevalier, have shown, by the present means it is not possible 
in a medico-legal investigation, to distinguish human blood from that of 
animals by the odour evolved from that fluid.^ Dr. Alfred S. Taylor takes 
occasion to say that after many trials with Barruel's process, he could come 
to no other conclusion than that it furnishes no criterion whatever, and 
that it would be dangerous to rely upon it in any case." 

Stains which may be Confounded with Blood- Stains. 

The substances producing stains resembling, in a greater or less degree, 
those produced by blood are exceedingly numerous, and it is very difficult to 
classify them satisfactorily. The appearance and reaction of stains made by 
metallic and vegetable dyes are often so modified by the presence of mor- 
dants or other chemicals as to be difficult to recognize, and on this account 
each medico-legal examination, to a certain degree, must be studied by itself 
according to the circumstances which are presented. 

Insoluble in Water. — From the chief characteristic of blood-stains — 

' Annales d'Hygiene pub., t. xlix. 1853, p. 413. 
2 Annales d'Hygiene pub., t. xxiii. 1840, p. 396. 
' Journal de Chimie Med., torn. v. 2me ser., p. 493. 

* Remarks on the Trial of Thomas Drury. Guy's Hospital Reports, vol. vii. p. 
372. 



1859.] 



Fleming, Blood-Stains. 



lot 



solubility in water — the substances of this class are readily distinguished. 
The principal of these are dragon's blood, Yenetian red (Indian red), red 
ochre (Spanish brown), vermilion, alkanet, precipitated carbonate of iron, 
colcothar, and iron rust. 

Soluble in Water. — Madder. This substance, used very much in dyeing, 
imparts to water a brownish colour, which is made crimson by addition of 
ammonia, and yellow by sulphuric and muriatic acids. This dye has ob- 
tained more notice since M. Raspail,* in a memoir read before the Academic 
Koyale, contested the value of the chemical characters of blood, and, ac- 
cording to him, these properties very well suffice to prove that a stain of 
blood is not a stain of rust, citrate of iron, cochineal, madder, &c., but 
they are not sufficient to show that the stain is truly of blood. He gave 
as proof, that having spotted linen and glass with white of egg which had 
remained for several hours in a linen bag with madder in powder, which 
had been previously moistened, the stains behaved towards reagents in the 
same manner as it had been said blood-stains reacted. These assertions of 
Raspail were completely refuted by M. Orfila,^ who showed the difference 
of reaction by several means, and among them : — 

1. That solution of alum and proto-chloride of tin only dilute the colour 
of blood, while the mixture of albumen and madder is rendered yellow by 
their solutions. 

2. That the colour of a mixture of albumen and madder is not destroyed 
by heat, when boiled together, as is seen constantly in dye-houses, where 
madder would be nearly useless if its brilliancy were so easily injured. 

In comparative experiments with a mixture of albumen with madder and 
colour of the blood, it is necessary to be careful that the latter contains no 
agent which prevents the loss of colour by heat, for, by neglect of this, the 
discrimination may be doubtful. 

Sanguinaria readily yields its colour to water and the solution bears a 
great similarity to blood. Its solution is coagulated and rendered bright 
crimson by addition of sulphuric and nitric acids, and completely decolour- 
ized by the addition of ammonia and potassa. 

Brazil Wood. — The colour of an aqueous solution of Brazil-wood is a 
dark brown, and is made crimson by ammonia, sulphuric and muriatic acids, 
and is deepened by bichromate of potassa. Logwood, the dye most fre- 
quent in domestic use, readily yields its colour to water, and the solution, 
which is a dark brown inclining to purple, is deepened by ammonia, red- 
dened by sulphuric acid, instantly changed black by solution of sulphate of 
iron, and blue by acetate of copper. 

Camwood and Bed Saunders are but slighly soluble in cold, more solu- 
ble in hot water, and rapidly so in acetic acid, alcohol, ether, and alkaline 



' Archives Gen., 1828, t. xvi. p. 299. 



2 Ibid., p. 161. 



108 



Fleming, Blood-Stains. 



[Jan. 



solutions. The colour is rendered violet-red by ammonia and potassa, and 
rose-red by sulphuric acid. 

Archil (Cudbear). Fruit stains, and the stains of plants and flowers, 
are changed to blue and green by ammonia. 

Sulpho-Gyanate of Iron, mixed with albumen, gives to water a striking 
resemblance to a solution of blood, but is instantly decolourized by addition 
of ammonia. 

Stains soluble in Water and unchanged by Ammonia. 

Citrate of Iron. — When blood in a thin stratum is dried upon a porce- 
lain plate, it shrinks and forms scales which are not unlike this prepara- 
tion. The colour of the solution of citrate of iron is deepened in the same 
manner as blood, but is quickly destroyed by addition of sulphuric acid 
which decomposes the salt. 

Anatto, dissolved in water, imparts an orange-yellow colour to water 
which is not decolourized by heat. The stain produced by this colouring 
matter is instantly changed to a dark blue by addition of sulphuric and 
nitric acids. 

Catechu, Bhatany, and Kino. — These substances form with water dark- 
brown solutions, and owing to the presence of tannin in large proportion, 
they can be with ease distinguished from blood. By the addition of a salt 
of iron, the latter becomes green, while, with the first two, the solution is 
changed to black. 

By a careful and minute comparison of the action of the various colours 
simulating blood, when treated by the different reagents, with the charac- 
teristics of blood under the same circumstances, it is seen that as yet no 
substance has been found which cannot be distinguished from it without 
difficulty, where sufiBcient .care and accuracy have been regarded in the ex- 
periments. 

II. Microscopical Examination op Blood-Stains. 

For some years past, the microscope has been resorted to, in order to 
distinguish fluids resembling blood, reddish stains of a suspicious character, 
and the blood of one animal from that of another. In no kind of investi- 
gation has the use of the microscope met with less opposition, and its 
merits so rarely called in question as in medico-legal evidence. Without 
this instrument many criminals would have escaped punishment, for, by its 
use, evidence, which was surrounded by doubts and difficulties, has been 
made substantial and clear, and frequently, things that were supposed of no 
moment, by its employment have been found connecting corroborative cir- 
cumstances, which, till then, seemed to have no relation whatever. The 
rapidity and accuracy with which blood can be recognized in a microscope 
of good construction, commend themselves in a question requiring all pos- 
sible certainty for its solution. The microscope not only furnishes the 



1859.] 



Fleming, Blood-Stains. 



109 



means of examining and defining objects invisible to the eye, but enables 
us to make, with facility, microscopico-chemical researches of the highest 
importance to the chemist and physiologist. 

It is needless to add, that familiarity with the instrument, and the sub- 
stances to be examined, is requisite to derive the advantages which it pos- 
sesses. 

Blood. — The blood is a slightly tenacious fluid of a specific gravity of 
1.055, and, when drawn from the vessels, presents to the eye a bright 
cherry-red colour, uniform in aspect, and separating, after a time, into cras- 
samentum and serum. When examined in the microscope, its peculiar 
bodies, the corpuscles, are seen floating in the liquor sanguinis, giving it 
the appearance of an emulsion, which, when the blood is traversing the 
vessels, permits us to note tlie course and its rate of movement. In the 
blood, three different forms of bodies have been discovered constantly pre- 
sent — the red globules or corpuscles, the white, and a smaller kind called 
molecules. For these, many different names have been given by distin- 
guished observers, but here I shall retain those in common use. 

Red Corpuscles. — The red corpuscles, which bear the colouring matter 
of the blood are, in man, shining, circular, slightly bi-concave cells, with- 
out a nucleus, and so numerous that to observe them satisfactorily, the 
blood requires to be diluted in some degree, or spread in an extremely thin 
layer. The colour of a single corpuscle, when viewed by transmitted light, 
is a dusky-yellow, but when piled one above another in mass, they are red. 
When the corpuscle lies on its edge, a bright-yellowish line only is seen. 
The diameter of a human corpuscle averages, according to the measure- 
ment of Hassall,* about ^gVo of an inch, and sometimes they can be found 
much larger. The number of corpuscles which exceed in size or fall below 
the standard, has been estimated by Carl Schmidt, to be only two per cent., 
so that the deviation scarcely affects the appearance presented to the eye 
in the field of the microscope. During the coagulation of the blood, the 
globules form into piles resembling coins, and by desiccation the walls 
shrink upon their contents, giving them a stellar form; the same result 
occurs when blood is mixed with urine and allowed to remain for some 
hours. The membrane of the corpuscle is very elastic, exceedingly delicate 
in structure, and is quickly affected by the action of reagents. In common 
vfith animal membranes, the corpuscles possess, in a high degree, the phy- 
sical property discovered by Dutrochet, of endosmosis and exosmosis, 
which renders them susceptible of rapid change in size and shape, and con- 
sequently in diameter, on the addition of a fluid having a difterent specific 
gravity from that of the blood, that demands an attentive consideration 
from the medico-legal examiner. 



' Microscopic Anatomy (Am. ed.), vol. i. p. 91. 
No. LXXTTI.— Jan. 1869. 8 



110 



Fleming, Blood-Stains. 



[Jan. 



On the addition of a small quantity of water, tlie corpuscles become 
thicker, and when more water is added they swell, assume a spherical form 
and burst, discharging their contents, leaving behind a circular line, as it 
were, its border. The same result follows when alcohol, ether, and crea- 
sote are added, but, at the same time, the corpuscles are rendered so trans- 
parent as with difficulty to be found. Potassa, soda, and ammonia in 
dilute solutions dissolve them. Phosphate, carbonate and sulphate of soda 
preserve their shape and slightly increase their size. Acetic acid extracts 
the colouring matter from the corpuscles, renders them white and perfectly 
transparent, and by degrees dissolves the membrane completely. By the 
tincture of iodine they are not altered in form, but the outline becomes 
more distinct. In a strong solution of corrosive sublimate, the corpuscles 
undergo no change of shape, but they have a more sharply defined outline 
and can be preserved in this for a long time. Chloroform makes the glo- 
bules bright yellow, causes the centre to appear and the outline to be indis- 
tinct. 

The blood-corpuscles are distinguished by peculiarities of form and size 
in the different classes of animals, that may enable us to recognize to what 
animal a certain specimen of blood belongs. In this respect, the micro- 
scope alone can aid us, since chemistry furnishes no means of estimating 
the shape and diameter of the corpuscles. In the mammalia, the corpus- 
cles are circular, and without nuclei, except in the elephant, camel, drome- 
dary, and lama, where they are found elliptical, biconvex, and containing 
nuclei. In birds, the corpuscles are elongated and fusiform in shape, with 
well-defined outline and nucleus ; and in the amphibia, they are oval, plainly 
convex, and have perceptible nuclei. The blood-corpuscles of embryonic 
life^ are larger, and sometimes as large again, as in the animal after respi- 
ration has been established, and present themselves in the shape of soft, 
round, but often irregular bodies, of a pale red colour. 

In order to obtain precise knowledge of the exact size of the corpuscles 
in different animals, resort has been made to micrometry by many celebrated 
observers, and the measurement of a number of specimens of each variety 
noted, to furnish data for accurate comparison. Latterly, for legal pur- 
poses, Carl Schmidt^ has, with great assiduity and astonishing perseverance, 
accomplished the task, and below will be found the result of his experi- 
ments with forty different specimens of blood of the animals named, except 
with that of the rat, mouse, frog, and chicken, in which there were twenty. 

The plan he at first adopted, was by drying blood in very thin layers 
upon glass plates. The size is given in millimetres, and the measurements 
of Gulliver are appended. 

1 R. Wagner's Thysiology by Willis, Lond. 1841, p. 248. 

2 Op. cit., nebeiisteliende Tafel. 



1859.] 



Fleming, Blood-Stains. 



Ill 



1. Blood-globules Dried in thin Layers, on Glass Slides. 





Man. 


Dog. 


Rabbit. 


Eat. 


Pig. 


Mouse. 


Ox. 


Cat. 


Horse. 


Sheep. 




0077 


0.0070 


0.00G4 


0.0064 


0.0062 


0.0061 


0.0058 


0.0056 


0.0057 


0.0045 


Minimum . . . 


0.0074 


0.0066 


0.0060 


0.0060 


0.0060 


0.0058 


0.0054 


0.0053 


0.0053 


0.0040 


Maximum . . . 


0.0080 


0.0074 


0.0070 


0.0068 


0.0065 


0.0065 


0.0062 


0.0060 


0.0060 


0.0048 


After Gulliver. 


0074 


0.0072 


0.0070 


0.0068 


0.0060 


0.0067 


0.0060 


0.0058 


0.0054 


0.0055 


Minimum . . . 




0.0056 


0.0051 


0.0048 


0.0048 


0.0048 


0.0048 


0.0054 


0.0048 


0.0032 


Maximum . . . 




0.0088 


0.0095 


0.0085 


0.0071 


0.0085 


0.0071 


0.0064 


0.0072 


0.0064 



Chicken 



Frog 



Breadth 
Length . 
Breadth 
Length 



Mean. 


Minimum. 


Maximum. 


L 0.0076 


0.0070 


0.0081 


0.0127 


0.0120 


0.0135 




0.0142 


0157 


0.0211 


0.0201 


0.0220 



To more closely approach standard measures for criminal cases, lie ex- 
perimented with blood dried in mass, and obtained the following : — 

2. Blood-globules Dried in Mass, on Wood and other Substances. 





Man, 


Pig. 


Ox. 


Horse. 


Sheep. 


Chicken. 






0.0034 


0.0030 


0.0028 


0.0022 


Breadth. 
0.0040 


Length. 
0.0074 




0.0037 


0.0030 


0.0028 


0.0026 


0.0020 


0.0038 


O.f'070 




0.0045 


0.0037 


0.0031 


0.0031 


0.0025 


0.0042 


0.0078 



White Corpuscles. — With the red globules are found colourless corpus- 
cles, which are far less numerous, but subject to great increase and diminu- 
tion in their relative proportion to one another under various circumstances, 
and more numerous than would be supposed from the careless observation 
of a single specimen of healthy blood. The white corpuscles are very deli- 
cate and highly elastic cells, globular in form in all kinds of blood, when 
not subjected to pressure, with a clear, shining border, and slightly granu- 
lar appearance in structure, containing nuclei varying in number. The 
term white, only serves as a distinction of the different bodies in red-blooded 
animals, for in insects the globules are all colourless, yet they are of dif- 
ferent sizes. The white corpuscles have an average diameter of 257^ of 
an inch ; in the mammalia they are larger than the red, while in frogs 
they are smaller. 

When submitted to the action of acetic acid, the outline is rendered 
transparent, the internal structure is coagulated, and the nuclei — v/hich, 
having a slightly reddish-yellow tinge, become visible — seem to unite and 



112 



Fleming, Blood-Stains. 



[Jan. 



adhere together. By the addition of water, they enlarge in size without 
alteration in form, when the granules plainly appear, resembling pus- 
globules in a striking manner. When to blood under examination, water is 
cautiously added, the red corpuscles soon swell and burst, while the colour- 
less ones are made perceptible, though before hid from the eye by the mass 
covering them. 

The number of white corpuscles is small compared with the red, and, 
according to the careful enumerations made by Moleschott* with the blood 
of different individuals, was 1 : 314 ; so that a specimen of healthy blood 
shows but a few of them in the field of the microscope. This proportion 
is, however, liable to great alteration ; and in the disease first noted by 
Yirchow, and denominated leukaemia, and independently, and almost simul- 
taneously discovered by J. H. Bennett, and by him called leucocythemia, the 
ratio is increased in some cases as high as 1 : 3. 

Some years ago, when studying this disease, or, more properly speak- 
ing, condition, of the blood, I was surprised at the destruction and total 
disappearance of the colourless corpuscles, when the process of desiccation 
had taken place, and that it was impossible to reproduce them in their 
normal state. My opinion in this respect, I find confirmed by the eminent 
microscopist, Ch. Robin,^ who says that, *'in blood which begins to dry, 
the white corpuscles change their shape ; their surface, which is more dense 
than the central portion, breaks and allows the contents to escape." It 
has been asserted by Prof. Wyman,^ " that by examination of blood dried 
on glass, painted wood, &c., to which water is added, after a careful in- 
spection, the observer will seldom be able to find any traces of blood-disks ; 
but transparent, colourless spots will be seen scattered through the mass, 
which, with a high power (say 800 diameters), may be seen to have a 
globular form and to contain granules — usually three or four. These are 
the lymph corpuscles." 

It is difficult to reconcile the remarks of Prof. Wyman with the rupture 
of the white corpuscles by drying, and I have tried again and again the 
experiment as described by him, and have not yet been able to discover in 
the dried blood any lymph corpuscles with their nuclei. Presumptuous as 
it may appear to doubt the accuracy of his observation, yet as the opinion, 
which I believe to be erroneous, has already found place, unchallenged, in 
a work^ of high standing, it is admissible to call it in question. The red 
corpuscles of the blood, when treated with water, become decolorized, as 
has been shown by L. Mandl,^ in one of the first contributions on the sub- 
ject, who says : " It is known that the globules of the blood, placed in water, 
are deprived of colour, and leave only a white bed formed of fibrin. The 

' Lelnnanu's Physiol. Chemistiy, Am. ed., vol. i. p. 611. 

2 Briand, Med. Legale, p. 788. 

3 Note by Prof. Wymaii in Report of Case of Jno. W. Webster. Boston, 1850, p. 90. 
* Wharton and Stillo, Med. .Jurisprudence, p. 5G2. 

5 Recher. Med. legales sur le Sang, These de Paris, 1842. 



1859.] 



Fleming, Blood-Stains. 



113 



blood-globules having lost their colour entirely, there remains no indication 
whether or not they are from the blood of a mammifera, since, in the fluid 
drawn from an ovipara, oblong nuclei, in great number, are seen in the 
midst of the white layer of fibrin." The same result takes place, I think, 
when dried blood is inspected in the same way, which explains the discre- 
pancy of opinion held on the subject. 

Molecules. — These minute spherical bodies of the blood do not enter 
into forensic investigations, and, consequently, require no consideration here. 

Derivation of Blood. — It frequently happens, in murder trials, when 
blood has been too plainly visible on the clothing of the prisoner, there is 
a defence made, explaining its presence by the killing of some animal, or 
by some natural cause. This can sometimes be contradicted, by finding 
mixed with the blood some substance which serves to denote its origin. 
The following illustrates this, in a trial at Norwich, England, a few years 
ago."* A female child, nine years old, was found lying on the ground, in a 
small plantation, quite dead, with a large and deep gash in the throat. 
Suspicion fell upon the mother of the murdered girl, who, upon being 
taken into custody, behaved with the utmost coolness, and admitted having 
taken her child to the plantation where the body was found, whence the 
child was lost by getting separated while in quest of flowers. Upon being 
searched, there was found in the woman's possession a large and sharp 
knife, which was at once subjected to minute and careful examination. 
Nothing, however, was found upon it, with the exception of a few pieces of 
hair adhering to the handle, so exceedingly small as scarcely to be visible. 
The examination being conducted in the presence of the prisoner, and the 
officer remarking: ''Here is a bit of fur or hair on the handle of your 
knife," the woman immediately replied: "Yes, I dare say there is, and very 
likely some stains of blood, for, as I came home, I found a rabbit caught 
in a snare, and cut its throat with the knife." The knife was sent to Lon- 
don, and, with the particles of hair, subjected to a microscopic examination. 
No trace of blood could at first be detected upon the weapon, which appeared 
to have been washed ; but, upon separating the horn handle from its iron 
lining, it was found that, between the two, a fluid had penetrated, which 
turned out to be blood — certainly not the blood of a rabbit, but bearing 
every resemblance to that of the human body. The hair was then sub- 
mitted to examination. Without knowing anything of the facts of the 
case, the microscopist immediately declared the hair to be that of a squirrel. 
Now, round the neck of the child, at the time of the murder, there was a 
tippet or "victorine," over which' the knife, by whomever held, must have 
glided ; and this victorine was of squirrePs fur / 

This strong circumstantial evidence of the guilt of the prisoner, was 
deemed by the jury sufficient for a conviction, and, whilst awaiting execu- 
tion, the wretched woman fully confessed her crime. 

' Chambers's Journal, part xxxv. Dec. 1856. 



114 



Fleming, Blood-Stains. 



[Jan. 



When blood is said to be derived from hemorrhages of various kinds, the 
truth or falsity of the statement can sometimes be found, by the discovery 
of a structure mixed therewith, peculiar to a certain part of the body, indi- 
cating its exact source. When from the nostril or lungs, by the admixture 
of the ciliary, and from the stomach and intestines, the columnar, epithe- 
lium. When from the bowels, by the presence of bile and feculent matter ; 
and from the urinary bladder, by the salts contained in urine. Menstrual 
blood is detected by the pavement epithelium peculiar to the vagina. 

Where fracture of the skull has been produced, the mixture of blood and 
brain matter known by the characteristic nerve-cells, found upon a bludgeon 
or other weapon, marks it as the destructive instrument. Should the poly- 
gonal cells of the liver be upon a knife supposed to have been used where 
a man has been stabbed in that organ, it would confirm suspicion. 

If the charge of stupration be brought, and blood-stains containing 
spermatozoa produced, it would be strong evidence that the crime had been 
committed, though, at the same time, it is not difficult to imagine that 
sperm could be obtained and surreptitiously mixed with blood in order to 
sustain a false a,ccusation. 

In like manner many other things and circumstances could be named 
w^here the presence of other substances with blood would elucidate the 
investigation of a case; but as they are so numerous, I have contented 
myself with naming a few of them. 

Blood-Crystals. — The colouring matter which in the blood remains in 
solution, when under favourable circumstances, is changed, and becomes a 
crystallizable material, furnishing crystals of beautiful colour and form. The 
merit of their discovery is granted to 0. Funke, who was very soon followed 
by F. Kunde, who succeeded in obtaining crystals from many different kinds 
of blood. It is most wonderful that this peculiar substance does not yield 
the same form of crystal in blood belonging to all classes of animals, which 
places within our reach a novel mode of recognizing in some cases, by the 
shape of crystallization obtained, to what animal a certain specimen of 
blood belongs, a fact not to be disregarded by the careful analyst who 
brings all knowledge to bear on the question. 

This interesting subject has received much attention from Lehmann,* who 
says the crystals occur in three forms — namely, in prisms, tetrahedra, and 
hexagonal tablets. The prismatic forms, whose true system of crystalliza- 
tion has not been firmly established, notwithstanding the attention which 
has been devoted to the subject, are peculiar to human blood and to the 
blood of most mammals and fishes ; the tetrahedra are met with in some of 
the rodents — as, for instance, in guinea-pigs, rats, and mice; while the hex- 
agonal tablets have hitherto been found only in squirrels. A glance at this 
attractive subject at once shows the advantage wiiich could be gained by 
resort to the crystallization of blood to determine its derivation. 



Op. cit., vol. i. p. 344. 



1859.] 



Fleming, Blood-Staius. 



115 



The method of obtaining crystals is to put a drop of blood on a glass 
slide, add a small quantity of water, alcohol, or ether, and then allow 
evaporation to take place slightly, covering it with a glass slip, first inter- 
posing a hair between the glasses, to afford room for the crystallization, when 
carmine-red crystals of different sizes will appear in from half an hour to a 
few hours or several days, according to the kind of blood and the situation 
in which it has been placed. The crystals are more rapidly obtained by 
exposure to sunlight, and more easily from defibrinated blood. The shortest 
time in which I have noted their formation was in half an hour, from the 
blood of a rat. The glass slip is not necessary, but very convenient in pro- 
ducing them, especially for the first essay, since they form quite well when 
exposed to the air and sunlight ; a little difficulty lies in knowing the 
proper quantity of water or other fluid to be added. 

Besides the bright-red crystals peculiar to blood are seen consociated 
those of chloride of sodium and phosphate of soda, which are found when 
either fresh or dried blood is submitted to the process of crystallization. 

The blood from which it is desired to make crystals does not require to 
be taken immediately from the vessels, but they are with less trouble pro- 
cured when it has stood from twelve to twenty-four hours; which is a great 
advantage when demanded in legal cases. It is somewhat difficult to pre- 
serve the crystals for a length of time perfect in form, and the best plan is 
by Canada balsam. I have, however, been able to keep them for several 
months, well enough to recognize them, by having so much blood and 
water on the plate that, when the glass cover is applied, the fluid will form 
a rim around the specimen, by the drying of which the object is sealed from 
atmospheric influence. It would appear that crystals are sometimes pre- 
served in a like manner when they form in clots, and there is no more cer- 
tain mode of identifying blood than by finding them. 

In an instance where blood-stains on cloth had remained for twenty-one 
months exposed to the atmosphere, Friedberg^ found this special kind of 
crystals, which he calls hasmatin-crystals ; and so very characteristic, that, 
in his opinion, one can with most perfect assurance prove the presence of 
blood when they are seen. Care must be taken not to mistake for them 
minute lamina, found in clots upon hard substances, whose accidental 
shape, when seen by a low power, sometimes simulates crystals. 

From blood which had been kept in dried clots for several months I 
have tried many times to obtain crystals, and lately have been successful in 
making some from ox-blood, preserved as above stated; which, however, 
were not very perfect specimens of crystallization. At the same time this 
is somewhat mortifying to acknowledge, yet it gives encouragement aud 
desire for further experiment. The plan adopted was to dissolve the clot 
in water, and allow it to stand until the corpuscles had all burst, then 



' Histologie des Blutes, Berlin, 1852, s. 71. 



116 



Fleming, Blood-Stains. 



[Jan. 



filtering the solution, and, after the addition of ether or chloroform, pro- 
ceed as with fresh blood. 

Dried Blood. — The vital fluid is so constituted as to possess an inherent 
power of self-preservation, whereby the anatomical constituent, the red 
corpuscles, provided no putrefaction has taken place, is retained by desic- 
cation in such a state that, upon the addition of certain fluids, the normal 
condition of the globules can be almost perfectly restored. Blood has been 
kept by many observers for different periods of time, and some as long as 
nine years, with no perceptible alteration. Before me are several specimens 
put away for five years, not having changed at all, without any further care 
than to keep them dry. 

The time required to soften the blood to such a degree as to reproduce 
the corpuscles varies from a few minutes to several hours, and is propor- 
tioned to the age of the clot and the tenuity or solubility of the reagent 
employed. Owing to the rapid endosmotic action which is found to take 
place in the corpuscles when a fluid whose density is lower than that of the 
serum is added to blood, by which they swell and soon burst, destroying 
their identity, some trouble has been experienced in the selection of menstrua 
which would most suitably answer the two purposes — of moistening the 
mass, and reinstating the corpuscles. For this purpose a great variety of 
fluids have been suggested and used, some of which have been esteemed by 
one observer, and disliked by another. 

Water. — In dried blood, where no decomposition has taken place, it has 
parted with its water by evaporation ; and it will readily recur to any one 
that by the cautious addition of water, in quantity proportioned to the size 
of the stain, a close imitation of the normal serum is made. When water 
is used, many of the corpuscles are sacrificed before its density has been 
raised, by the salts and other elements of the blood, to that of serum; and 
when this has been done, the globules are seen floating about, with well- 
defined outline. This reagent is more particularly useful when the stain is 
very old, for in recent specimens, when submitted to its action, the endos- 
mosis is so violent as to destroy the corpuscles. There is perhaps no fluid 
in use for softening masses of blood which requires more care and experience 
than water, and it is well to take the precaution to scrape a small portion 
of a clot on to a plate, and, after placing the same in the field of the instru- 
ment, add the water, when the reaction can be observed. 

Serum. — The objection to the use of serum is the difficulty of obtaining 
it entirely free from corpuscles ; and to obviate this, the contents of hydro- 
celes have been employed. That serum might be employed for this purpose, 
F. W. Bocker^ has, very ingeniously, proposed to filter human or other 
mammalian blood, and to employ the serum thus obtained for the examina- 
tion of frog's blood, or that of the ovipara; and, in like manner, to take 
the serum of frog's blood to mix with the blood having round corpuscles. 

' Memoranda der genchtliclien Medizin, Iserlohn, 1854, s. 281. 



1859.] 



Fleming, Blood-Stains. 



117 



Albumen. — This substance, as presented in the white of an egg, has 
been talcen for the microscopic examination of blood, and has been found 
free from many o])jections belonging to other substances. 

Glycerine. — This menstruum has been highly commended by Dr. Alf. S. 
Taylor,^ on account of its close approach in specific gravity to that of 
serum, and the slowness with which it evaporates. The ease of obtaining 
glycerine of purity is another advantage which it possesses. With albumen 
and glycerine a slight refraction of light takes place, which might disturb 
the vision of one unaccustomed to microscopy. 

Besides the above, oil, solutions of sugar and sulphate of soda, liquor 
amnii, and an aqueous solution of iodine, to which sugar has been added, 
have been used by different individuals for bringing the corpuscles in relief, 
and allowing them to be quickly recognized, but none are so free from 
objection as albumen and glycerine. 

The blood-corpuscles can be preserved so well for several years, that they 
retain their characteristic shape, and indicate accurately the race of animal 
to which they belong, by simply spreading them on a glass slide, in a very 
thin layer, when, by blowing upon them, or waving the slide back and forth 
in the air, to make vaporization take place rapidly, these bodies are fixed, 
and may be permanently prepared by putting a frame of gold size around 
them, and applying a cover. The contraction of the contents takes place 
equally on all sides, whereby their form is preserved. 

Carl Schmidt^ is of opinion that "the drying of blood globules of different 
animals, isolated or in mass, adheres to the same rule of evaporation as the 
pollen of a flower, and the coefficient of desiccation in all of them bears a 
constant relation to the diminution of their volume. The micrometric de- 
finition proves this presumption, and gives us the solution of the most diffi- 
cult problem on this point, the diagnosis of certain kinds of animal blood, 
in a dried condition, from one another and from that of man." This 
plausible and philosophical opinion seems to forestall any doubts or diffi- 
culties which might be raised from inspecting dried blood, and unfortunately 
it is not fully borne out in all practical cases, forcing one, however enthu- 
siastic he may be to claim for the microscope the highest merited confidence, 
to acknowledge there are circumstances when it fails to discriminate posi- 
tively the dried blood of one animal from that of another. 

Some alteration in the form of the corpuscles is produced by drying upon 
substances of a porous nature, whereby their integrity is injured. In the 
Marylebone Police Court, in the case of Wm. Styles, Dr. HassalP made 
the following remarks directly bearing on this question : While the deter- 
mination, by means of the microscope, of the nature of blood-stains, even 
when very recent, formed on cloth, linen, and other soft and porous tex- 
tures, is usually a matter of considerable difficulty, and is often impossible, 

' Medical .Jurisprudence, 4tli Am. ed., p. 239. 

2 Op. cit., s. 5. 3 Lancet for 1852, vol. i. p. 321. 



118 



Fleming, Blood-Stains. 



[Jan. 



the determination of sucli stains, however old, as are placed on glass, porce- 
lain, wood, and other hard or smooth surfaces, is in general unattended 
with diflBculty, and extremely satisfactory. This difference is to be ex- 
plained thus : in the one case the fibrin, albumen, and serum of the blood 
are in part absorbed and pass into the cavities of the hairs or fibres of the 
wool or linen ; the blood-corpuscles are thus deprived of their preservative 
fluids and shrink up — become misshapen or disintegrated ; while in the 
other case the fibrin and albumen harden around the blood-disks in drying, 
and thus preserve them slightly altered in form only. 

The difficulty is further well illustrated in the following case : A man 
walking alone on the street, received a blow in the face which stunned him 
and caused the blood to flow ; on recovering, he found himself robbed of 
his money. A labourer was arrested on suspicion, on whose pantaloons 
was found a large blood-stain, which he said was produced in helping to 
kill a cow. The stained garment was submitted to microscopical examina- 
tion, in which Profs. Du Bois and Reymond participated. Answer of 
committee : Blood-corpuscles of ox blood can only be discriminated from 
human blood-corpuscles by their smaller size. On examining fresh blood of 
oxen and fresh blood of man, the human corpuscles are found to be larger, 
and could be easily recognized even on admixture with the smaller ones of 
ox blood. Some threads saturated with blood were cautiously taken out 
of the blood-stained pantaloons and macerated in pure bone oil ; on bring- 
ing the preparation under the microscope, the form of the blood-corpuscles 
was found too indistinct to warrant a conclusion as to their nature. The 
blood-stain was at least three, if not six, weeks old, at which time the cor- 
puscles have acquired their shrivelled appearance, which always gives un- 
certain results. In order to examine the opposite opinion of Schmidt, the 
following experiment was made : fresh human and fresh ox blood was put 
upon the pantaloons, and allowed to dry for a week. The blood-stains 
were then softened in bone oil and brought separately and mixed up under 
the microscope. It seemed as if the dried human blood had more resem- 
blance to the blood found on the garment than the dried blood of the ox, 
but the form and diameter of both kinds of blood-corpuscles were so much 
changed by shrivelling, that conscientiously a discrimination could not be 
made.^ 

Bocker^ says that " sometimes by the drying of blood the corpuscles are 
destroyed, when only shapeless little masses or roundish granules remain, 
whose true nature it is impossible to discover microscopically. I have, 
among others, a specimen of dried pigeon blood, three years old, in which 
I and several practised microscopists cannot discover a single elliptical or 
oval blood globule, whilst very many round granules of the size of human 
corpuscles are seen. Moreover, I have found the bird's dried blood, when 
moistened with a solution of sugar, or in fresh filtered serum of frog's 



Op. cit., von J. L. Casper, s. 157. 



2 Op. cit., s. 282. 



1859.] DaCosta, Blowing Sound in the Pulmonary Artery. 



119 



blood, contains a great many round, indeed, cliiefly round, corpuscles very 
similar to those of human blood, and it is often necessary to search a long 
while before an elliptical one is found. In human and mammalian dried 
blood, I have never found elliptical blood corpuscles." 

After numerous and carefully conducted experiments, Friedberg^ mourn- 
fully acknowledges " that the solution of the most difficult problem — the 
diagnosis of the blood of man and certain mammalia, in a dried state, as 
Schmidt has announced as positive in all cases — is still a piiim desiderium, 
and it is not possible by the present known means of examination to dis- 
tinguish them, as the results of the many systematic experiments I have 
made authorize me in saying." 

Ritter,^ in his well digested and carefully arranged prize essay, takes 
occasion to remark that " in his researches he has not found the facts as 
interpreted by Schmidt, and agrees with the conclusions of Friedberg." 

From the experiments which I have made during a period of several 
years with blood belonging to different animals, when dried for a length of 
time and moistened again, I am forced to admit that great difficulty arises 
in attempting to fix its origin by the comparative size of the corpuscles ; 
and again, that the blood of ovipara, when kept for several weeks, does not 
present the peculiar elliptical corpuscles found in fresh blood, in a form 
sufficiently perfect to justify me in declaring positively whence it proceeds. 

PiTTSBUKG, Pa., Oct. 20, 1858. 



Art. YIII. — On the Occurrence of a Blowing Sound in the Pulmonary 
Artery associated with Affections of the Lung; on the Sounds of the 
Artery in Health, and on the Effect on them and on the Heart of the 
Act of Inspiration. By J. DaCosta, M. D., Lecturer on the Practice 
of Medicine at the Philadelphia Medical Association. 

In examinations of the chest, I have met with a peculiar physical sign — 
a blowing sound in the second intercostal space on the left side — the occur- 
rence of which has only been imperfectly alluded to, and the importance of 
which is not settled. The following notes of cases will explain its signi- 
ficance. 

Case I. Wm. Moore, age 35, a clerk by profession, placed himself under 
my charge September 8, 1857, for phthisis. He belongs to a family in which 
consumption has made sad ravages ; his father and grandfather, brothers 
and sisters, having died of the disease. He had had, when first seen, seve- 

1 Op. ext., s. 57. 

^ Ueber die Ermittelung von Blut, Saamen, "und Exrementenflecken in Krimi- 
nalfaellen. Wiirzburg, 1854, s. 139. 



120 Da Costa, Blowing Sound in the Palmonaiy Artery. [Jan. 

ral hemorrhages ; had lost flesh; and was troubled with a cough, followed 
by a yellowish expectoration. His pulse was 112, and feeble. The upper 
portion of the right lung was found dull on percussion, with crackling 
and prolongation of the expiratory murmur. On the left side, a slight 
dulness existed anteriorly at the upper portion, and the respiration was 
harsher than normal. It is not necessary here further to detail the case; 
it need only be added that he has remained under observation for upwards 
of a year, and that the most marked improvement, both in the symptoms 
and physical signs, has followed the administration of cod-liver oil and the 
iodide of iron. No advance of the disease has taken place in the left lung. 
During the period he has been under my care, I have repeatedly noticed that 
a blowing sound — at times low, at times of a higher and more whistling 
pitch — existed in the interspace between the second and third ribs on the 
left side. It was synchronous with the heart's impulse, and followed by a 
distinct second sound. In some examinations, in which the heart was beat- 
ing slowly and the patient breathing quietly, it was not perceived, espe- 
cially not at the last (in November, 1858). I do not, however, believe that 
it has disappeared entirely. The other sounds of the heart were perfectly 
normal, as was its impulse and the extent of the percussion dulness. No 
arterial or venous murmurs were noted. 

Case II. Charles Boyd, age 18, a shoemaker, came under my care May 
24, 1858. He had had a cough for three months, attended with emacia- 
tion and night-sweats. Slight dulness existed at the upper portion of the 
right lung, also crackling and prolonged expiration; a friction sound was 
noted at the upper portion of the left lung, anteriorly, near the second rib, 
and dry rales were heard there, as, indeed, over the entire extent of that 
lung and of part of the right. The case was diagnosed as one of tuber- 
culosis, probably of both lungs, certainly of the right, accompanied by an 
attack of bronchitis. The bronchitis soon yielded to remedies employed 
for its removal. On the 8th of June, no r^les were perceived. There was 
then crackling in the right lung, rude inspiration, with marked prolonged 
expiration ; whilst in the left lung the respiration was harsh, the friction 
sound being still heard; also — what previously (although it may have been 
present) had not attracted attention — a rather short blowing sound, at times 
of high whistling pitch, then again of a lower note, in the second intercostal 
space, and synchronous with the heart's impulse. No blowing sound ex- 
isted over the heart ; nothing abnormal was noted about the impulse or size 
of the organ. The further history of the case, until the patient was lost 
sight of (in September), is soon told. The crackling at the upper portion 
of the right lung became larger and moister, and more decided signs of in- 
filtration in the left lung took place. When last seen, the blowing sound 
in the pulmonary artery still existed, and, under excitement, was almost 
distinctly sibilant ; it was heard best when the patient held his breath in 
expiration. 

Both these were undoubtedly cases of phthisis. The blowing sound in 
neither, from their not having been under observation when first attacked, 
can be stated to have occurred with the earliest indications of tubercular 
infiltration. In the two cases which follow — and for the opportunity of re- 
cording which I am indebted to my friend, Dr. Francis W. Lewis — the 
blowing sound was noticed when the signs of disease of the lung were far 



1859.] DaCosta, Blowing Sound in tlie Palmonary Artery. 



121 



from being satisfactory, or even unequivocally present, but the progress of 
the cases showed it to be associated with tubercular disease. In Cases Y. 
and YI. which are still under observation, the physical signs and symptoms 
indicate phthisis in its earlier stages, and the blowing sound is, in both, 
quite distinct. 

Case III. In the spring of 1854, I saw several times, with Dr. Lewis, 
Hugh Burns, £et. 28, a coachman, who had the physical sign in question 
very well marked. He had consulted Dr. Lewis in March, 1853, for cough 
and dyspnoea. He was then a man of florid appearance, not in the slightest 
degree emaciated, but very much addicted to the use of tobacco. He com- 
plained of having suffered occasionally from palpitation of the heart, had a 
slight cough, and had had a hemorrhage from the lung about a fortnight 
before. The physical signs at that time were negative as to a deposit. 
No abnormal modification of the vesicular murmur was found in the right 
lung; if any existed in the left, it was obscured by a very distinct, rather 
harsh blowing sound, heard to the left of the sternum. The patient was 
placed upon the use of cod-liver oil. When he was again seen, six months 
afterwards (in September), he had had several hemorrhages. The left 
lung was evidently the seat of a tuberculous deposit. I examined him about 
this time ; he was somewhat emaciated, coughed, and presented dulness at 
the upper portion of the left lung with harsh inspiration. The hloiving 
sound was very distinct, especially after exercise. When the heart was 
acting quietly, it was softer, and not always easily perceptible. Its situa- 
tion was at the left of the sternum in the second intercostal space; it ex- 
tended from thence slightly upwards, and occurred synchronously with the 
impulse of the heart. There was no enlargement of the organ, no blovfing 
sound over the heart or in the arteries of the neck. The further history of 
the case showed that the tubercle gradually infiltrated both lungs, cavities 
formed at the apices, dysenteric complications occurred, and the patient died 
exhausted on September 19, 1854. The blowing sound had not disap- 
peared when his chest was last examined, after cavities had fairly formed, 
and when he was sinking. Subsequent to this, he grew so weak, that an 
accurate examination of the chest could not well be made. 

Case IY. Sarah Gray, aet. 36, married, of scrofulous aspect, had been 
salivated severely for rheumatic iritis, after which she fell at once into feeble 
health. Her symptoms, when seen on March 3, 1853, may be briefly stated 
as follows. She was emaciated, coughed, the circulation was feeble and irre- 
gular, and her menses had stopped. A physical examination revealed slight 
feebleness of respiration at the upper anterior portion of the left lung, 
and a distinct systolic blowing sound at the base of the heart, not propa- 
gated into the aorta, and not heard in the vessels of the neck. It could 
be localized near or over the sternum, opposite the third rib. The heart's 
action was frequent, and the impulse strong. In July, unmistakable signs 
of tubercular deposit appeared in the left lung. She grew weaker and 
weaker, and died in January, 1854. The blowing sound was distinctly 
heard a few weeks before her death. An autopsy showed extensive disease 
of the left lung. It was, throughout, the seat of a tubercular deposit, and 
contained cavities. The right lung presented only a few scattered tubercles. 
None of the abdominal viscera were affected. The heart was not enlarged, 
the valves were healthy. No abnormal state of the pericardium, nor of 
the vessels proceeding from it, was noted. The exact position of the pul- 



122 DaCosta, Blowing Sound in the Pulmonary Artery. [Jan. 



monary artery to the deposit was, owing to the circumstances of the exa- 
mination, not specially studied. 

Case Y. Sarah C , ^t. 41, consulted me October 30, 1858, with re- 
ference to a cough which she had had for nine months. She had lost flesh 
and had spat blood twice within the last week, not much in quantity, but 
red and unmixed with expectoration. Occasionally she has had night- 
sweats. The cough was very troublesome, especially when she laid down 
at night. The appearance of the woman was not that of anaemia. She 
did not complain of shortness of breath; her respiration was not hurried ; 
there was no pain at . any portion of the chest. On percussion, I found 
general clearness throughout both lungs ; but at the upper portion of the 
left lung, anteriorly, especially between the second and third ribs, slight dul- 
ness was noticed, and an increased resistance to the finger. On close inspec- 
tion, a sinking in at the upper portion of the lung was observed. In the 
right lung the vesicular murmur was normal ; in the left lung the respira- 
tion throughout the whole upper portion of the chest, anteriorly and poste- 
riorly, was rude; rudest, however, at the apex, anteriorly. The heart's 
sounds were normal ; the impulse and the extent of percussion dulness not 
increased. Between the second and third ribs, an inch to an inch and a half 
from the edge of the sternum, on the left side, was heard with each beat 
of the heart a rather abrupt but distinct soft blowing sound; after it, an 
accentuated second sound. The murmur was not perceived at all over the 
heart, nor even at the left edge of the sternum. It did not extend up higher 
than the second rib, and was not heard with each impulse. No blowing 
sound existed over the aorta. I^o venous or arterial murmurs were dis- 
cerned in the neck. The sound seemed only to be occasionally produced, 
and was best heard at the first few minutes of the examination ; after tiiat 
it was not constant. The patient complained of some pain on pressure be- 
tween the first and second, and second and third ribs. It was not noticed 
that any acts of respiration caused marked changes. The blowing sound 
seemed to be more particularly distinguishable after a series of full inspira- 
tions, and to be in time simultaneous with the expiration. 

Case VI. James Dogherty, age 18, is noted in N'ovember of this year 
as having been ailing for nine or ten months with pains in the chest and a 
cough. He is very liable to colds, and then the cough increases. At no 
time since February has he been free from cough. He has lost flesh, and 
has on several occasions expectorated blood, upwards of a tablespoonful in 
quantity; yet he neither looks, nor expresses himself as feeling very feeble. 

On examining his lungs, the left lung yielded at the upper portion a 
somewhat duller sound than the right ; the respiration at the whole of the 
upper portion of the left lung, anteriorly, was rude. 

The percussion dulness over the heart was more extended than usual ; 
the impulse also was stronger. The sounds at the apex of the heart, and 
at the aortic cartilage, were normal ; at the pulmonary valves (edge of the 
sternum, left side) the second sound was much accentuated; between the 
second and third ribs, about an inch from the edge of the sternum, was dis- 
cerned, with the impulse of the heart, a short, rather musical blowing 
sound, over a space which could be covered with the stethoscope. The 
sound was best heard when the patient was standing erect, and at the com- 
mencement of the examination. It seemed also most distinct after a full 
inspiration. When he was quietly seated, the sound was not perceived. 
No venous or arterial murmurs were observed. 



1859 ] Da Co ST A, Blowing Sound in the Pulmonary Artery. 123 



That these patients all suffered from phthisis need hardly again be stated. 
In all of them the blowing sound existed, unconnected with blowing sounds 
in the heart, or in the arteries of the neck. In all, the blowing sound was 
synchronous with the impulse, and in five, situated in the second intercostal 
space. In reviewing these six cases, we are struck with the fact that the 
murmur was evidently among the earlier symptoms in four; and further, that 
although it was not always equal in intensity, as far as observed it did not 
disappear entirely. But on this point I do not wish to speak decidedly, 
since some of the cases have not been watched long enough to permit of a 
conclusion. In the last two observations some room for doubt as to the 
correctness of the diagnosis may exist, but not much ; not more than is pre- 
sent in any case of incipient pulmonary disease in which there has been 
hemorrhage, and in which slight dulness, with a modification of the vesicu- 
lar murmur, is detected at the apex of the lung. Were it not from having 
observed the next two cases, I might have arrived at the conclusion that a 
blowing sound in the second intercostal space absolutely belongs to tuber- 
cular infiltration of the lung ; but they disapprove this idea, and show how 
the sound may be associated with other than tubercular affection. 

Case YII. Ter. McGinnis, age 33, a labourer of healthy appearance, 
consulted me in August, 1858, for fugitive pains in the chest, especially of 
the left side. His case is noted as follows : In December, 185Y, having 
previously been in excellent health, he was seized, after exposure, with a 
fever and severe pain in the left side, which confined him to his bed. His 
breathing at that time was short, but he recovered from the attack without 
any further annoyance than an occasional cough and some pain in the 
chest. He has not lost any flesh ; never spat blood ; and has no cough ; 
indeed, with exception of the pains which trouble him occasionally, he is 
in good health. Neither his respiration nor his circulation is increased in 
frequency, nor has he difficulty of breathing. The upper part of the left 
lung, anteriorly, is duller on percussion than the upper part of the right. 
The inspiratory murmur throughout the left lung, but especially at its upper 
portion, is harsh ; the expiration there prolonged. The voice is distinctly 
heard over the left lung. Yesicular murmur is normal throughout the 
right lung. Size of the heart normal ; sounds normal ; at the left side of 
the sternum, between second and third ribs, the second sound of the pulmo- 
nary artery is remarkably accentuated and sharp sounding, much more so 
than the aortic on the opposite side ; in a line more outwards a short dis- 
tinct hloiving sound is heard, corresponding to the impulse of the heart, 
over a spot about an inch in length ; it is marked when the patient is in 
the erect position, and the heart is beating strongly. — He was directed to 
rub his chest with a stimulating liniment, which relieved the pain. 

On September 28, the physical signs were the same ; his general health 
was good, and he was able to do his work. The blowing sound was heard 
well when the heart was acting rather strongly. I have seen him once since ; 
he w^as attending to his daily duties, and in good health. No murmurs in 
the arteries or veins of the neck were at any time perceived. 

Case YIII. A C , age 22, consulted me in September, 1858, for 

a pain in the chest and a cough which he had contracted at a watering-place. 



124 DaCosta, Blowing Sound in the Pulmonary Artery. [Jan. 



The physical signs indicated slight bronchitis of the right lung. The pain 
was mainly post-sternal. The cough w^as trifling, and, under the use of expec- 
torants and a turpentine liniment, both it and the pain had in the course of 
three weeks entirely disappeared. The previous health of the gentleman had 
been excellent. He did not recollect ever to have had an acute disease of 
the lung. IsTo hereditary tendency to tuberculosis existed in the family. 
He had, when last examined (November 11), not a vestige of cough remain- 
ing, and was in very good health, excepting a slight enlargement of the 
tonsils, and sore-throat, which has at times troubled him for years past. 
When first ausculting his chest, I was struck with a distinct bloiving sound 
in the second intercostal space of the left side. It was soft, low-pitched; 
but became, when he was breathing frequently and his heart was excited, 
of a higher pitch, and more like a sibilant rale. The sound was noted at 
his first examination ; at the last, two months aft-erwards, it was still 
present. Its more particular character may be gleaned from a note taken 
during one of the examinations after the signs of bronchitis, and the 
cough had entirely left. 

On percussion, the lungs are clear throughout. There is relative dul- 
ness, with a higher pitch at the upper portion of the left lung. This is 
especially marked between the second and third ribs, where there is also 
more resistance, and a slight sinking in perceptible. On auscultation, the 
vesicular murmur is normal throughout the right and the greater portion 
of the left lung. At the upper portion of the left lung it is harsher and 
stronger than normal, although the expiration is not prolonged; between 
the second and third ribs it is feebler than higher up ; and the inspiration is 
distinctly jerking, or rather divided. The percussion dulness of the heart 
is not marked until the fourth rib is reached. The impulse is natural in 
extent, force, and situation. The heart-sounds, at the apex, at the ensiform 
cartilage, and close to the sternum on the right side in the second inter- 
costal space, are natural; on the left side, about half an inch from the 
sternum, in the same intercostal space, is heard a blowing sound, corre- 
sponding to the impulse, and followed by a very accentuated and marked 
second sound, which is more accentuated and marked than the second aortic 
sound. When the heart, after exertion, is beating rather strongly (the 
pulse counted being 78), and the breathing hurried (28 times a minute), 
tlie blowing sound becomes like a sibilant rale. It is best heard when the 
expiration is held, or immediately after the inspiration. When a long 
l)reath is drawn and held, the murmur can hardly or not at all be discerned, 
and the second sound is very indistinct, but becomes afterwards, during ex- 
piration, very sharp and distinct. The sound has the sibilant character 
only very occasionally if the heart is beating quietly and the breathing not 
hurried. Under these circumstances, also, it cannot be readily perceived with 
every impulse of the heart. Over the spot indicated no other sound occurs, 
corresponding in time to the first sound of the heart, and no pain or pulsa- 
tion exists. 

No blowing sound could be discerned in the arteries or veins of the neck. 

The physical sign in question may, then, be stated as being a murmur 
attending the impulse of the heart, almost alw^ays soft and low-pitched, 
although occasionally harsher, of higher pitch, and simulating a sibilant 
rule. Its situation is in the second intercostal space on the left side, 
not an inch from the edge of the sternum. It may be audible higher 
up; or, again (as in Case lY.), opposite the third rib, on the sternum. 



1859.] Da Co ST A, Blowing Sound in the Pulmonary Artery. 125 

The space it occupies is usually very limited, and can be accurately circum- 
scribed with the stethoscope. It is not heard during a full inspiration, but 
very distinctly after inspiration, or with expiration. It takes the place of 
the first sound at the spot it is heard, but is followed by a distinct second 
sound. When the patient is breathing quickly, and the heart's action ex- 
cited, it is best distinguished. It is not always of equal distinctness or of 
equal pitch, but it is not transitory, as it maybe observed extending over a 
long space of time. The sounds of the heart are not influenced by it. They 
are heard with the usual clearness at the apex, immediately above the ensi- 
form cartilage ; at the third rib, or second intercostal space, on the right 
side ; at midsternum ; and even at the third costal cartilage and edge of 
sternum, on the left side. At this latter situation the second sound is dis- 
tinctly heard ; the occurrence of the first is more difficult to perceive and 
more doubtful. 

Before inquiring into the cause of this sound it will be necessary briefly 
to recall the anatomy of the parts, as w^ell as some clinical points with 
reference to examinations of the heart. If a long needle be stuck into the 
chest, in the second intercostal space on the leftside, immediately below the 
cartilage of the second rib, it strikes the pulmonary artery near its bifurca- 
tion. The valves of the pulmonary artery are seated at the junction of the 
cartilage of the third rib with the sternum on the left side. IN'ear them, 
somewhat lower, lie the aortic valves ; and lower still, and inwards, about 
on a level with the fourth rib, at midsternum, are the tricuspid and mitral 
valves. The fact that the valves are so close together has led to the 
seeking for points at which the sounds may be isolated, and these are, 
following the course of the vessels, for the aorta, the second intercostal 
space close to the right edge of the sternum, or the second costal carti- 
lage ; for the pulmonary artery, from its ascending on the left side, the 
second costal cartilage, or the second interspace near the left edge of th^^ 
sternum. These points for the aorta and pulmonary artery are spoken 
of, for convenience sake, as the ''aortic cartilage" or interspace, or the 
"pulmonary cartilage" or interspace. jSTow, the pulmonary artery is in- 
closed in its whole extent by pericardium, within which membrane it usu- 
ally divides. The left pulmonary artery passes then through the pericar- 
dium, a layer of which is prolonged upon the vessel ; surrounded by this 
and the reflection of the pleura, it is met with at the root of the lung. 
It, however, soon enters the pulmonary texture and subdivides, at a point 
immediately over the fourth dorsal vertebra, and, as may be readily seen 
by removing the sternum, opposite the junction of the lower border of the 
second costal cartilage with the corresponding rib. 

As the blowing sound is heard so exactly in the position which we have 
just seen to indicate the course of the pulmonary artery, and especially at 
a point just before or even at the bifurcation of its left branch, we shall 
regard its seat as certain, and may next proceed to discuss its cause. 
No. LXXIII Jan. 1859. 9 



126 Da Costa, Blowing Sound in the Pulmonary Artery. [Jan. 

All blowing sounds in the heart or in arteries are due either to a peculiar 
condition of the blood, or to the presence of local obstructions ; or, again, 
they may be transmitted. This latter supposition cannot be entertained, as 
there was no murmur anywhere to be transmitted, the heart in all the eight 
cases yielding perfectly normal sounds. 

Was the murmur inorganic, the blowing sound that of angemia? oS'o; 
for, independently of the fact that in Cases YII. and YIIL, as well as in 
Case III. when first seen, not the slightest signs of anaemia existed, it is in 
nearly all especially noted that there were no blowing sounds in the arteries 
of the neck, or none of those venous murmurs which usually occur in 
watery states of the blood. I am aware that a blowing sound in anaemic 
women may be more marked at the base of the heart over the pulmonary 
artery than over the aorta ; but is it persistent, merely distinguishable there 
and unaccompanied by a venous hum? Certainly this must be of very rare 
occurrence. In Case TV. the blowing might be thought to have been in- 
organic, from the history of the case, and from its being perceived near the 
sternum ; but even here its purely local character, and the absence of mur- 
murs elsewhere is against this supposition, and still more so is it in the 
other cases. 

If the blowing sound was not inorganic, and not transmitted, it must have 
been owing to local lesions of the pulmonary valves, or of the artery. Now, 
morbid states of the pulmonary valves occur so rarely, as hardly to be 
considered in a point of diagnosis. Moreover, the site of the greatest 
intensity of the blowing sounds in such cases would be at the sternal edge 
of the third left cartilage, which it was not in the cases reported, excepting, 
perhaps, in one ; in which, however, an autopsy demonstrated the absence 
of valvular lesion. Nor were there in any of the patients signs of cardiac 
disturbance ; hence, diseases of the pulmonary valves certainly could not 
have been the cause of the murmur. 

The last consideration, is that the murmur was caused by local changes 
or obstructions in the pulmonary artery. This might be owing to deposits 
in the coats of the vessels, or to a healthy state of the artery itself, the 
murmur being produced' by pressure on the artery. That it was the latter, 
and not the former, I believe, because, 

1st. Deposits in the coats of the pulmonary artery are uncommonly rare. 
2d. The cases having occurred mostly in young persons, the age of the 

patient excludes deposits. 
3d. The murmur was usually soft, but became sometimes of a more 

whistling character. 

On this point I lay less stress, but the other two are sufficient. It might 
sclso be added, that the autopsy in Case lY., whilst it is not satisfactory 
as to the exact condition producing this blowing sound, is so, as far as it 
showed no abnormal state of the coats of the vessels. 



1859.] DaCosta, Blowing Sound in the Pulmonary Artery, 12*7 

These blowing sounds are, then, capable of explanation by local pressure, 
or rather a want of yielding of the textures surrounding the left pulmonary 
artery, or one of its branches, during the diastole or expansion of the ves- 
sel, and when the blood is propelled through it. Masses in the pericar- 
dium have been noticed to produce a murmur in the pulmonary artery. 
Why should not, then, in some persons, in whom the position of the artery 
is such as to be easily compressed by the lung, infiltration of the surround- 
ing textures — especially if pleuritic adhesions exist at the upper lobe, which 
would keep the lungs from fully expanding — prevent the vessel from fully 
and equally distending, and thus give rise to a murmur ? This might occur 
the more readily, because, as will be presently shown, the first sound at the 
pulmonary artery is usually dull and indistinct, and would easily permit of 
a murmur being perceived or taking its place. Whether this explanation 
be adopted or not, the fact that in all the eight cases local signs of partial 
consolidation were met with, seems to bring these local signs in connection 
with the peculiar murmur. I do not claim to have discovered a new physical 
sign. My only wish has been to endeavour to fix the value of a sign which 
experience has taught me occurs in a certain number of cases. Dr. Latham, 
long ago, pointed out the occurrence of a blowing sound at the upper part 
of the left lung, in persons who were undeniably tubercular, or suspected of 
being so. From some reason or other, little heed has been taken of his 
observation ; but that it is entitled to consideration the cases reported prove, 
although they also prove that non-tubercular deposits may occasion this 
murmur. On the whole, however, they show that where slight changes are 
observed at the apex of the left lung, with symptoms which lead to a 
suspicion of tuberculosis, where there is an absence of any symptoms or 
signs which point to a previous attack of pleurisy or pneumonia, and 
which would account for the physical signs at the apex, the presence of a 
localized systolic blowing sound on the left side, unaccompanied by venous 
murmur, ought to have a decided diagnostic significance : in what propor- 
tion of cases it occurs remains, however, yet to be fixed. 

In the course of this clinical inquiry, two points have arisen on which 
some light may be thrown by a comparison with phenomena in health. 
The blowing sound took the place of the first sound over the pulmonary 
artery. What are the natural sounds heard there, and how produced ? 
Secondly, full inspiration prevented the sound from being heard. What is 
the effect of full inspiration on the sounds of the artery ? 

For the purposes of an accurate standard in examinations of cardiac 
affections, I have studied and compared with each other, with care, the heart 
sounds in the different portions of the organ, and also the effect of the respi- 
ration on them. I shall insert here as much as is relevant to the subject of 
the consideration of sounds in the pulmonary artery, merely adding that 
the usual clinical positions have been selected — the second intercostal space 
near the sternum, on the right side, for the aorta ; on the left, for the 



128 Da Co ST A, Blowing Sound in the Pulmonary Arteiy. [Jan. 



pulmonary artery; whilst the sounds at the apex have been studied a little 
above the left apex, and above the ensiform cartilage. Where the term 
apex merely is used, it is meant to apply to the apex beat on the left side 
of the heart, between the fifth and sixth ribs. 



Comparative Observations on the Sounds of the Pulmonary Artery. 



t 

<» fl 
o 






6 


1 j< 


Character of sounds of pulmonary artery. 


O 


)< 

CO 


fen 


S 






1 


M. 


12 


72 


19 


First sound very dull, indistinct, of much lower pitch than second, 
which is sharp and accentuated and rery marked at left edge of 
sternum. 


2 


M. 


22 


70 


24 


Sounds in 3^11 rGspccts tliG sfiiii© \ no diffcrcncG tctwccn 3;0rtic Hnd. pul- 












monary ; first sound at the left apex is much longer. 
Both sounds distinctly heard ; first sound of low pitch ; second sound 
unusually" strong and accentuated. As compared with the aortic 
sounds, the first pulmonary was of lower pitch "but the second 
seemed in all respects equal. The first sound at the apex was very 


3' 


F. 


24 


96 


25 










23 


much longer and more weighty. 


4 


M. 


13 


80 


Both sounds heard ; first, dull, of low pitch ; as compared with aortic, 












second aortic is much more distinct ' no difference between the first. 
First sound very dull, of low pitch, and very indistinct ; second sound 
sharp. 


5 


F. 


15 


75 


20 


6 


M. 


22 


80 


19 


First more like an indistinct vihration, of low pitch, no defined sound 
heard ; second, sharp, accentuated, best heard at left edge of sternum ; 












first aortic, also, is very dull \ second more marked than second pul- 
monary ; first sound at apex long, heavy and distinct. 










20 


7 


M. 


30 


72 


Both sounds distinct * first much duller than second which is most 
accentuated at edge of sternum ; second aortic more accentuated than 












second pulmonary j no difierence hetween first 
First sound very dull, almost imperceptible ; second marked, most so 
at edge of sternum. As compared with aortic sounds, first duller, of 
lower pitch, but more prolonged ; second less accentuated. At apex 
of heart, first sound is dull, heavy, and long. 


8. 


M, 


22 


50 


15 


9 


M. 


26 


72 


20 


First sound indistinct, dull, of lower pitch, less sharp than first aortic. 
Second not nearly as accentuated as second aortic. First, at apex, 
dull, hut heavy and prolonged. 


10 


M. 


23 


72 


20 


The same results. 




M. 


25 


74 


24 


Both sounds distinct j first is rather duller, longer, and of low^er pitch 
than first aortic, but as distinct or distincter ; second aortic is sharper 
and more accentuated. First, at apex, dull, but very distinct, heavy, 
and longer than first pulmonic : first, at ensiform, rather sharper. 


12 


M. 


26 


72 


19 


also less sharp and accentuated than second aortic. At apex, first 
is much heavier and prolonged. 


13 


M. 


22 


84 


18 


The same ; except no appreciable difference between first aortic and 


14 


M. 


21 


96 


19 


The same as in Observation 12. First sound of pulmonary artery is 
not as sharp, and more diflicult to distinguish, than first aortic. 


15 


M. 


25 


96 


21 


The same. First of pulmonary artery very dull and of low pitch, 
more like an indistinct vibration. First, over ensiform, shai-per. 


16 


M. 


24 


72 


18 


First sound dull, low pitched, and so indistinct as to be almost imper- 
ceptible. Second accentuated and distinct, but not as much so as 
second aortic. First aortic, also, is sharper and better marked ; 
sounds shorter. At apex, first sound is dull, prolonged, but not very 
heavy. 


17 


F. 


44 


82 


25 


First sound at pulmonary dull and indistinct ; second marked, less 
accentuated than second aortic. No difference between first pulmo- 






















nary and first aortic. First, at apex, is dull, much more prolonged, 












and heavy ; and very distinct. 


18 


F. 


30 


72 


20 


First sound at pulmonary dull, but marked ; no difference between it 
and aortic first ; seems a little more distinct. Second pulmonary 
more marked than second aortic. First, at apex, dull, but very much 
more distinct and prolonged than first pulmonary. 


19 


M. 


58 


70 


19 


First sound at pulmonary very dull, low pitched, indistinct, hardly 
perceptible ; second marked, but far less so than second aortic. 
First aortic sharper, higher pitched than first pulmonary. At apex, 
first is much more prolonged, quite distinct, and heavy. 


20 


M. 


22 


76 


24 


First pulmonary indistinct and dull, more so than first aortic. Second 
pulmonary less accentuated than second aortic. First, at apex, dull, 
but distinctly heard ; much longer than first pulmonary. 



» This person was troubled with occasional shortness of breath, but the size of the heart was not 
increased, the beat was frequent, the impulse distinct. 



1859.] Da Co ST A, Blowing Sound in the Pulmonary Artery. 129 

It will be seen from this table, that the firet sound of the pulmonary 
artery is usually dull, of low pitch, and, in certain cases, more like a 
vibration than a sound, or so indistinct as hardly to be perceptible. 
Compared with the first sound of the aorta, it is equal in a certain num- 
ber of instances (it was in six out of eighteen in the table) ; but when 
it differs (in eleven out of eighteen), it is noticed to be less distinct, less 
sharp, although, it is in some persons a rather longer sound. Compared 
with the first sound at the apex of the heart, it lacks the weighty, pro- 
longed, marked character of this sound. If the stethoscope be carried up 
from the apex of the heart to the second interspace, the difference is ob- 
served to be very marked ; the change of sound occurs almost abruptly. 
It seemed to me, also, as if a decided change in pitch took place ; but I do 
not wish to speak too positively on this point, as it is a very difficult mat- 
ter to distinguish changes of pitch in sounds, both of which are dull, and 
one very indistinct. Compared with the first sound over the right ven- 
tricle (above the ensiform cartilage), the first pulmonic is of a much duller 
character, and decidedly less sharp, and not of as high a pitch. In this re- 
spect, the difference — not merely in the above observations, but in others 
I have made — was noticed as much more decided than between it and 
the first sound over the left ventricle ; the one on the right side being, 
although less strong and shorter, usually clearer, and of higher pitch even 
than this. 

These analyses, showing that the somids of the heart, listened to in dif- 
ferent positions, differ in character, are thus in favour of the view that the 
first sound of the heart, as heard over the arteries, is not merely a trans- 
mitted sound, but is one which — to a great extent, if not entirely — is gene- 
rated by the coats of the vessels themselves during their diastole. They 
would further tend to show that the first sound of the heart, as heard over 
the apex on the right side, is not transmitted from one side to the other, 
but is formed by each ventricle separately. 

As regards the second sound in the pulmonary artery, as compared with 
the second aortic sound, it need only here be said that the latter is usually 
far sharper and more accentuated. Out of the eighteen cases compared, it 
was stronger in fifteen, equal in two, less marked only in one. 

A second point with reference to the blowing sound capable of being 
somewhat elucidated by a comparison with health was, why was it inaudi- 
ble during a full inspiration, and so marked in expiration ? The following 
table, by exhibiting what effect a full inspiration has on the sounds of 
the heart in health, will explain it, especially if, in addition, it be borne in 
mind that the sound is sometimes of the same pitch as the inspiratory 
murmur, and that in expiration the heart's action is quickened. Ten young 
adults were selected, whose hearts, as far as the extent of percussion- 
dulness, rhythm, and impulse, proved, were perfectly normal. 



130 DaCosta, Blowing Sound in the Pulmonary Artery. [Jan. 

Effect of a full Inspiration {the breath being held) on the Heart. 



At, or rather 
somewhat above, 
ensiform car- 
tilage. 



At apex of heart. 



Second interspace 
on right side be- 
tween car- 
tilages. 



Second interspace 
on left side of 
sternum. 



Effect on impulse, 
and extent of 
percussion 
dulness. 



Both sounds some- 
what lessened; 
first most. 



First disappears ; 
second is heard 
tolerably dis- 
tinctly, not quite 
as distinctly as 
previously. 



First sound more 
indistinct; second 
not much chang- 
ed. 

First lessens ; se- 
cond seems to 
gain. 

The same. 
The same. 



Both sounds heard 
but are somewhat 
lessened. 

Both sounds 
heard; no change. 



First sound lessen- 
ed ; second seems 
to increase. 

Sounds not much 
lessened. 



Both sounds much 
lessened. 



The same. 



Both sounds some- 
what lessened. 



First sound disap- 
pears ; second 
faintly and dis- 
tantly heard. 



Both sounds al- 
most disappear; 
second least. 

The same. 



Second disappears, 
in proportion, 
more than first. 

First disappears 
almost entirely ; 
second can be 
heard, although 
faintly. 

Both sounds some- 
what lessened. 



First sound duller, 
less distinct ; se- 
cond hardly 
heard. 



Both soiinds less- 
en ; first propor- 
tionably most. 

Both sounds be- 
come very indis- 
tinct. 



The sam€ 



The same; second 
not heard. 

First disappears 
entirely ; second 
heard as a small 
tick. 

First sound disap- 
pears ; second 
heard with toler- 
able distinctness. 

First sound does 
not disappear, al- 
though very in- 
distinct ; second, 
only slightly less 
distinct, is well 
heard. 

First disappears ; 
second well 
heard. 

The same ; second 
does not disap- 
pear, somewhat 
lessened. 



Neither sound 
heard ; second oc- 
casionally, but 
only very faintly 
and distantly. 



The same. 



Nothing heard. 



First disappears ; 

second heard only 

faintly. 
The same. 



Both disappear. 



First disappears; 
second very faint- 
ly heard. 

The same. 



The same ; second, 
however, is dis- 
tinguishable. 

The same ; second 
very faintly 
heard. 



Impulse of heart 
moves downward 
and inward to- 
wards median 
line ; at previous 
seat of impulse, 
impulse is very 
feebly felt. 

The same ; the ex- 
tent and shape of 
percussion dul- 
ness alters ; at 
the upper border, 
it shifts nearly an 
inch ; sounds 
heard distinctly 
over the shifted 
impulse. 

The same. 



The same ; dulness 
moves by an inch. 

The same ; dulness 
moves by three- 
quarters of an 
inch. 



The same. 



The same. 



These observations, which have been repeated on other eases with similar 
results, show, then, the effect of a full inspiration on the heart sounds to 
be an almost entire disappearance of the sounds heard at the interspace 
between the second and third ribs on the left side, and a very great, 
but not as marked a diminution of the sounds at the aortic cartilage. At 
the apex, the first sound lessens very much, and becomes in some persons 
almost imperceptible ; the second also is modified, but proportionally less 
than the first. Over the ensiform cartilage, the sounds lessen least. In- 
deed, the second sound, in four cases out of ten, was distinctly increased ; 
and in two cases, in which the first sound became much more indistinct, the 
second was heard almost unchanged. These changes were all noticed in 



1859.] BuEL, Topography and Diseases of Panama. 131 

those who were capable of taking a very full inspiration and holding it for 
some time, and were constant on repeated examination. I believe, although 
the proximity of the valves to each other renders it impossible to speak 
conclusively, that this accentuated second sound, heard at the spot men- 
tioned, is that of the pulmonary valves, and has become more marked, 
owing to the fact that during a full inspiration, the heart's action is slower, 
more laboured, and the circulation of the lung probably interfered with ; 
thus, the pulmonary artery would be distended, and the backward stroke 
of the column of blood against the semilunar valves be more forcible. 

The fact that the heart sounds are in a full inspiration less distinctly 
heard at points at which they were previously well perceived, may be 
explained by the lung being carried in front of the heart, which it does 
more on the left than the right side, and, to some extent, by the relative 
displacement which occurs during the act of inspiration. The apex, espe- 
cially, is displaced ; it moves down in some persons, by several inches, 
towards the pit of the stomach, and becomes almost imperceptible at its 
previous point of impulse. This displacement seems to me to be brought 
about, not only by the depression of the diaphragm, but by the pressure of 
the lung on the left side of the heart, a fact of which I have convinced me 
by observations, which it is only necessary here to allude to, and which 
will be found elsewhere detailed.^ 



Art. IX. — Notes on the Medical Topography, Climate, and Diseases of 
Panama, N. G. By Wm. P. Buel, M. D., Surgeon Pacific Mail Co. 

The city of Panama, by reason of its geographical position, historic 
associations, and commercial importance, is an object of interest to the 
philosopher, the statesman, and the man of science. Planted on a narrow 
neck of land, which connects two great continents, and separates two 
mighty oceans, it stands like a gateway, through which must pass a great 
amount of the world's commerce. Already it has regular steam communi- 
cation, on the east with England, the United States, the West India Islands, 
and the Atlantic ports of South America ; on the west with all the princi- 
pal ports of the South Pacific ; with Central America, Mexico, California, 
Oregon, and the British possessions. At no remote period, Australia, the 
Sandwich Islands, and China, will be added to this already extended list. 

Topography. — The present town of Panama is situated in lat. 8° 
K, and Ion, 19° 31' W. ; in the northern half of that tropical belt which 
supplies us with coffee and sugar; spices and dye-woods; cinchona and 



' See Transactions of the College of Phjsicians of December 1st. 



132 BuEL, Topography and Diseases of Panama. [Jan. 

sarsaparilla ; opium and camphor, and many other most important drugs. 
The original city stood a few miles to the eastward of the present one. A 
few ruins are all that remain to mark the ancient site. A venerable old 
tower still survives, hoary with age; and which, probably, witnessed the 
mustering of Pizarro and his band of adventurers, when he was about 
setting forth on his memorable expedition for the conquest of Peru. 

The modern town stands at the head of the bay of the same name, on a 
tongue or neck of land projecting into it. In shape, it is an irregular 
equilateral triangle, having its base towards the land, and with water on its 
two sides. A wall and rampart surround it, with bastions and curtains toward 
the sea, and a ditch on the land side. These fortifications, though they 
may have been a defence against Morgan and his buccaneers, serve at 
present to exclude nothing but pure air ; and the health of the city would 
be improved by levelling them to the ground — a process which time and 
the elements are gradually, but surely accomplishing. 

The sides of the triangle are about three-fourths of a mile in length, and 
the intramural space is regularly laid out in streets, crossing each other at 
right angles. As in all tropical towns, the streets are narrow; not gene- 
rally more than 20 feet in width. The houses, from two to three stories 
in height, are built up with heavy masonry, with balconies projecting from 
the upper stories over the streets. There is considerable space within the 
walls not occupied by streets or houses, lying uncultivated, but covered 
with the dense vegetation of the tropics. Many old churches and convents, 
deserted and in ruins, furnish evidence of former opulence and large popu- 
lation. Outside the walls, a considerable town has sprung up. The whole 
population is estimated at from ten to fifteen thousand souls; all, with the 
exception of a comparatively small foreign population, using the Spanish 
language. They are by no means generally, however, of pure Spanish 
blood, but a mongrel race of Spanish, Indian, and African. There are but 
very few families who claim to be of pure blood ; and even of these few, 
the genealogical tree will not, it is said, bear too close an inspection. 

The climate is not friendly to the white races. The light-complexioned 
children one meets about the streets, are pale and ansemiated, with narrow 
chests and slender attenuated limbs. The African race, on the contrary, 
thrive and flourish. Their muscular frames and well-developed limbs offer 
a striking contrast to those of the white race. Some of the most extra- 
ordinary specimens of muscular development we have ever met, are to be 
found among the negro coal-heavers employed by the mail company. They 
would form a model for the sculptor. 

The geological structure of the neighbourhood of Panama, and, indeed, 
of the whole isthmus, is volcanic. The mountain ridges shoot up every- 
where into peaks and truncated cones ; evidently craters of extinct volca- 
noes. The rocks are all trap or basaltic. The older rocks contain fissures, 
into which streams of lava, the result of more recent eruptions, containing 



1859.] 



BuEL, Topography and Diseases of Panama. 



133 



boulders of different sizes, have evidently been poured. The soil is a 
reddish loam, of no great depth, but of extreme fertility ; producing, with 
little cultivation, in great profusion, every variety of tropical growth, 
whether fruit, plant, or flower. The isthmus is rich in medicinal plants, 
many of which are known only to the natives. As tonics and febrifuges, 
they employ Quassia (Quassia Amara), Cedron (Simiba Cedra), and 
several varieties of Gentian. The Cedron bean is also regarded as a pow- 
erful antidote against the bites of serpents, and stings of scorpions and 
other poisonous insects. Sarsaparilla grows abundantly upon the isthmus. 

The country, in the immediate neighbourhood of Panama, is an irregular 
plain of several miles in extent ; here spreading out into broad and beauti- 
ful savannahs, and there rising into sudden and abrupt declivities, some of 
them several hundred feet in height, but clothed to their summits with a 
dense vegetation. There are pools and spots of stagnant water in the 
neighbourhood, but no extensive swamp or marshes. At no great distance 
from the city, the country becomes broken, and rises into steep hills and 
mountain ridges, through which the railroad winds its tortuous way, until 
it reaches the summit, about ten miles from Panama. The isthmus is not 
distinguished by high mountains. The mighty Andes, when approaching 
this narrow neck of land, decreases into a ridge of hills seldom attaining 
the height of a thousand feet. The railroad winding through the irregu- 
larities of the mountains, has only a grade of something less than three 
hundred feet to be overcome. 

Climate. — The year divides itself into rainy and dry seasons. The rains 
commence in the spring — soon after the sun in his journey northward has 
crossed the equinoctial line — and continuing, with more or less regularity, 
during the whole period that he is north of the equator, terminate not 
long before he reaches the line again in his journey south. South of the 
equator on the South American coasts, the seasons are exactly reversed ; 
there the rains commence about the time of our autumnal equinox, and 
terminate about the time of our vernal. The law is the same in both cases, 
viz., the rains follow and accompany the sun. Farther north the rule is 
exactly reversed. In California, the rainy season is when the sun is in the 
far south ; the dry when it is farthest north. It is easy to see why the 
cooling process, which takes place in California during the winter months, 
should condense the atmospheric moisture upon the sides of the mountains, 
and bring with it copious rains. It is not so easy to explain why the same 
rule should not hold good in the intertropical regions. 

The rains, which at first are but passing showers, gradually increase, and 
are fully established towards the end of May, when they fall in torrents, 
sometimes for days in succession, and are accompanied by thunder and 
lightning of the most terrific description. With the exception of a few 
days about the 24th of June, called by the natives the Yeranito de San 
Juan, analogous to our Indian Summer, the rains continue for six or eight 



134 BuEL, Topography and Diseases of Panama. [Jan. 

months. During this time, fogs, calms, and light, variable winds prevail. 
The air is loaded with so much moisture, that leather cleaned in the morning 
is often loaded with mould in the evening. 

During the wet season the thermometer (Fahr.) ranges from to 85°, 
seldom falling below the first or rising above the last. This is not an 
extreme degree of heat ; but the extreme humidity, by preventing all evapo- 
ration, clogs the perspiration, and produces a sense of oppression not expe- 
rienced in a dry atmosphere with the same or even a higher temperature. 

Towards the end of December the rains diminish in frequency, and with 
the commencement of the new year the northwest wind sets in. An imme- 
diate change follows. The air becomes pure and refreshing, the sky blue 
and serene. Hardly a cloud is to be seen ; and there being but little moisture 
in the atmosphere, the heat, though ranging from t5° to 90° Fahr., is less 
oppressive. The nights are almost always cool, with a strong breeze from 
the northwest, which makes a blanket generally comfortable to sleep under. 
The early morning is cool and pleasant; but about 9 o'clock the breeze dies 
away, and from that hour till 2 or 8 o'clock P. M. the heat is intense. The 
evenings at this season are deliciously cool, the air fresh, the sky without a 
cloud, and the stars glittering with a splendour known only in the tropics. 

Diseases. — Panama has the reputation of being a place of extraordinary 
insalubrity — a sort of a hot-bed of disease — v/here the fever which bears its 
name reigns with undivSputed supremacy. This is in a great measure unjust. 
Among intertropical cities, it is more healthy than the average. When it 
is considered that it is compactly built, surrounded with walls which exclude 
the air and prevent free ventilation — that it has no sanitary police, no sew- 
erage — that the filth which in other cities is either carried off in underground 
sewers or received into deep cesspools, is here left to fester upon the surface 
— when all these facts are remembered, Panama may be considered a healthy 
town. A strong evidence on this point is, that no epidemic disease has ever 
prevailed here extensively — neither cholera, nor yellow fever, nor dysentery, 
nor any other form of epidemic disease. Sporadic cases of all of them are 
of occasional occurrence, but seldom or never in an epidemic form. When 
yellow fever is prevailing at the island of St. Thomas, between which and 
Aspinwall there is constant intercourse by the semi-monthly steamers, spo- 
radic cases of the same disease often occur on the line of the railroad and 
at Panama ; but the disease does not spread extensively. 

The most prevailing diseases, and those which maybe considered endemic, 
are dysentery and that form of miasmatic fever variously called Panama, 
Chagres, or isthmus fever, termed by the natives "calentura." It is com- 
paratively a mild form of febrile disease, and perfectly controllable by qui- 
nia, with very little other medication, and no preliminary treatment. The 
Spanish physicians, with the attachment to ancient modes and practices so 
strong in their race, still insist upon bloodletting as an indispensable pre- 
liminary to the quinia ; thus entailing upon their patients a tedious conva- 



1859.] 



BuEL, Topography and Diseases of Panama. 



135 



lescence in a climate where the vital energies are low, and the recuperative 
process never rapid. 

Bronchial affections are very common among the native population, ac- 
companied oftentimes with obstinate cough and a profuse expectoration. 
Tubercular phthisis is of occasional occurrence, but is comparatively rare. 
Smallpox and the other exanthems are met with, but usually in a mild 
form, and are seldom epidemic."^ 

The most sickly period of the year is usually towards the termination of 
the wet and at the commencement of the rainy season, or the months of Sep- 
tember, October, and November. Dysentery is then very common; and 
also a high grade of bilious fever, which in malignity and fatality falls little 
short of yellow fever — and is attended by the same yellow tinge of the skin, 
injected conjunctiva, and irritable stomach which mark so strongly that 
disease. Quinia, so effectual in the ordinary fevers of the country, is in this 
almost or quite powerless. It often runs to a fatal termination in from 
four to eight days from the commencement of the attack, with sometimes 
hemorrhages from the mouth and gums, and symptoms of congestion in the 
brain, lungs, or liver. These malignant cases are, happily, not of frequent 
occurrence. 

The foreign population of Panama is not numerous; it is composed of 
citizens of the United States connected with the railroad company and the 
Pacific Mail Company in different capacities, and a few French, English, 
and Germans, engaged in commercial operations. Some few of this class 
of the foreign residents enjoy uninterrupted health ; the majority experience 
attacks of fever more or less frequently, and in the intervals of exemption 
suffer from the depressing and debilitating effects of the climate. It may 
be doubted whether there is any such thing, for natives of northern and tem- 
perate regions, as acclimatization in tropical climates, so as to enjoy an ex- 
emption from their peculiar diseases equal to that of the native population. 
If it ever occurs, it must be considered the exception, not the rule. 

Hospitals, and Provision for the Sick. — Some years ago, when the tide 
of California emigration was at its highest pitch, there were at times as 
many as two or three thousand Americans congregated at Panama, waiting 
for a passage to California. Among these masses many were destitute, 
many dissipated and imprudent, and all unaccustomed to the climate. Much 
sickness, of course, prevailed. To meet this, private hospitals were opened 
by physicians, as a speculation. This answered very well for those who had 
funds, but afforded no relief for the large number of destitute. To meet 
the latter exigency, a public hospital for Americans was opened, supported 
in part by voluntary subscriptions, and in part by a capitation-tax upon 

' Since the above was written I learn that about twentj-five years since there 
was an epidemic of smallpox, which committed extensive ravages. Many people 
of twenty-five years and upwards are seen about the streets, badly pitted, survivors, 
doubtless of that epidemic. 



136 KiNLOOK, Pseudarthrosis of Bones of Forearms. [Jan. 

passengers. But, with the exigencies that required them, all these have long 
since ceased to exist. Sick and destitute Americans are succoured by private 
charity; or, if mariners, by the American consul. The French population 
have a small hospital, sustained in part by voluntary contributions, and in 
part by the French government. 

For the native population there is a hospital with a permanent endow- 
ment. The hospital building was erected for the purpose about ten years 
since. It stands without the walls, in one of the streets of the suburbs. 
It is a long one-storied stone structure, and, with its tier of small windows, 
elevated eight or ten feet above the street, and heavily grated, has more the 
aspect of a prison than a hospital. It has four or five wards, with a kitchen 
and office, opening on a corridor with pillars and arches of heavy masonry. 
Over one of the doors of the main entrance is an inscription with these 
words: ''Yenite ad me, omnes vos qui laborates et estis onerate, 
ET EGO VOS reficiam." The whole aspect of the interior is a sad com- 
mentary upon this gracious invitation. The wards are dark and ill-venti- 
lated, scantily furnished with a few old iron bedsteads without mattresses 
or pillows. The patients are mostly old chronic cases, sent here merely to 
prevent their dying in the streets, and without the slightest hope or expecta- 
tion of recovery. And as if to say to every unfortunate patient who enters 
the place, there is but one possible way of leaving it, a grim display of old 
coffins, of all sizes and styles, from plain wood to shabby black velvet, occu- 
pies the most conspicuous place in the corridor already mentioned. In this 
country, to be buried in a coffin is a luxury only for the rich. The poor man 
is borne to the grave in a coffin, the body interred, and the coffin reserved, 
to be used over and over ; so that these hospital coffins may have borne 
a whole generation to their long home. This place, its inmates, and every- 
thing connected with it, wear an appearance of squalid filth and hopeless 
misery, which are a disgrace to any community calling itself civilized. 

Panama, N. Gr., October, 1858. 



Art. X. — Case of Pseudarthrosis of the Bones of both Forearms; Fail- 
ure of Brainard's Operation, and of Excision. By R. A. Kinlock, 
M. D., Surgeon of the Roper Hospital, Charleston, S. C. 

Nicholas Yanderwich, a Hungarian, aged 32 years, of exceedingly 
robust and athletic appearance, and enjoying perfect health, was admitted 
into the Roper Hospital, on the 8th of March, 1856, on account of false 
joints of the bones of each forearm, the result of fractures sustained ten 
months previously, while residing near Georgetown, S. C. The fractures 
were occasioned by a heavy chain falling from a height, and striking the 
forearms while the upper extremities were outstretched, and the hands 



1859.] KiNLOCK, Pseudarthrosis of Bones of Forearms. 131 



grasping a horizontal bar. He had received surgical attention at the time, 
but the apparatus employed became frequently deranged, and the surgeon, 
living at a distance, could see him only at long intervals of time, conse- 
quently the result was ununited fracture of the four bones. For many 
months he had been without any adjustment, and daily used his arms to 
the best of his ability, to procure a livelihood. The examination at the 
hospital revealed well-marked false joints, situated nearly midway between 
the wrist and elbow joints of both forearms ; those of the right side were a 
little higher up than those of the left. There was marked shortening of 
both forearms, they appearing very disproportionate to the length of the 
arms. What was the precise amount of shortening could not be determined, 
as we were unable to make the comparison between an injured and a sound 
limb. The right forearm, however, was shorter than the left, because of 
greater riding of the fragments. The fragments of the right limb were only 
loosely held together, while those of the left were more nearly in apposition, 
and well secured to each other by short ligamentous union. The ends of the 
eight fragments were smooth and rounded off, as far as could be discovered 
through the soft tissues. The flexor and extensor muscles of both the fore- 
arms were shortened from permanent retraction ; the muscular fibres seemed 
doubled up on each other ; extension and counter-extension occasioned but 
little muscular elongation, and overcame in no material respect the riding of 
the fragments. The prehensile movements of the hands were perfect, and 
so were the functions of the elbow and wrist-joints, and the movements of 
flexion and extension ; pronation and supination were limited. The mus- 
cles of the forearms, like those of the entire body, were powerful, and the 
patient could lift, with the hands, very heavy weights to a certain extent 
perpendicularly from the earth ; when, however, the arms were outstretched 
horizontally, they were comparatively useless. 

It was evident, then, that an operative procedure offered the patient the 
only chance of relief from his distressing condition. Union of the bones was 
all that we could expect to secure; to overcome the riding, and to restore 
the natural movements of pronation and supination, seemed practically im- 
possible. The patient's robust health inclined us to expect nothing from 
constitutional treatment. The length of time that had elapsed since the 
occurrence of the fractures, and the present condition of the parts impli- 
cated, forbade us to hope anything from absolute and long-continued rest 
of the fragments, or from such moderate excitation as could be induced by 
friction repeated from time to time. We agree with Mr. Syme, of Edin- 
burgh, that of the many operative procedures employed for the cure of pseu- 
darthrosis, the resection of the bones involved, or, in other words, the cutting 
out the false joint, is the most rational, and the one most likely to be 
followed by success. But surgeons, as well as their patients, naturally and 
properly shrink from very severe operations, where there is a reasonable 
prospect of cure by milder ones. Of the milder means, I concluded to select 
the procedure lately described and known as ''Brainard's operation," be- 
cause of the great success attributed to it, and because, practically, it was 
to me a novelty. With the left forearm, I had every hope that it would 
succeed ; but I scarcely beiieved that it would prove serviceable with the 
right. I resolved to operate first on the left member alone, and allow 
the patient the use of the right ; by so acting, I would not subject him 
to as much inconvenience, and there would be more certainty of securing 
for the desired time absolute rest to the member operated on. These ad- 
vantages I conceived to more than counterbalance the disadvantage which 



138 KiNLOCK, Pseudarthrosis of Bones of Forearms. [Jan. 

would arise from consecutive operations necessitating his remaining at least 
double the time under treatment. 

March 11. The patient being fully under chloroform, the left arm held in 
a semi-prone position by an assistant, I introduced one of Brainard's drills, 
subcutaneously, upon the posterior and radial aspect of the member, imme- 
diately over the false joint ; this was then carefully forced on until the point 
reached the portion of the upper radial fragment, in close proximity to the 
abnormal articulation. This fragment was steadied with the fingers and 
thumb of the left hand, applied respectively upon the anterior and posterior 
aspects of the forearm, while a perforation was effected with the drill ; the 
instrument was then withdrawn from the opening made in the bone, with- 
out being allowed to repass through the soft tissues, and the point fixed 
upon an adjacent spot, where a second perforation was accomplished, and 
after this a third in close proximity to the two others. The lower frag- 
ment was then attacked, and several perforations made with the drill, the 
left hand steadying this as it had previously done the upper fragment. 
Finally, the point of the drill was carried between the ends of the frag- 
ments, and turned about so as to lacerate their connecting fibrous medium ; 
then, for the first time, it was withdrawn through the original cutaneous 
puncture. While perforating, the point of the drill was always directed 
from the important structures lying to the ulnar side of the radius. The 
fragments, and the false joint of the ulna, were now operated upon in the 
same manner ; the point of the drill, during the procedure, being directed 
from the important parts now lying to the radial side of the bone. The 
operation finished, the small cutaneous wounds were dressed with collodion 
and lint ; the member was put up as after a recent fracture ; an anodyne 
was given, and the patient sent to bed. He suffered from day to day very 
little inconvenience ; the arm was kept at rest by the apparatus — which was 
only once or twice disturbed in a fortnight, to permit an examination of 
the progress of the case — but he was allowed the freedom of the ward. 

April 4. Considerable callus was found to have been deposited ; but as 
yet there was nothing like consolidation. I repeated the drilling operation 
on the left forearm ; and thinking that success would soon be attained, and 
the use of this memlDer consequently permitted, I decided to operate at once, 
and after the same manner, on the right forearm, so as to save the patient 
time. The operations were conducted as before described. Considerable 
pain and some swelling succeeded the operation on the right member. 

12^/i. The swelling of the right forearm had increased to an extent which 
rendered it necessary to remove the apparatus and readjust it, for fear that 
the circulation of the limb might be interfered with. 

lith. The apparatus removed from the left forearm, and the parts care- 
fully examined. Union of the ulnar fragments seemed to be promised, as 
the consolidation was more decided than upon last examination ; the radial 
fragments were quite free, and no callus discoverable around them. 

lUh. Patient complains of increased pain of the right forearm; this 
found to be more swollen. The adjustment was removed, when careful 
manipulation discovered a purulent collection upon the posterior and radial 
side of the member. The abscess was punctured, and found to be small and 
circumscribed. 

18^/?. Condition of right forearm much better; swelling greatly subsided. 

May 13. All swelling and excitement having disappeared from right 
forearm, and there seeming to be no attempt at union, I resorted again to 
the drilling. 



1859.] Ktnlock, Pseudarthrosis of Bones of Forearms. 139 

21st. Right forearm again suffering from abscess at the radial side; this 
I opened, and found more extensive than the last. 

22d. Left forearm examined, and found consolidated. The drilling ope- 
ration repeated. 

23c?. Another abscess of right forearm was opened posteriorly, and more 
towards the ulnar side than the last one. 

June 3. Still another small abscess of the right forearm evacuated ; the 
apparatus was removed, and the member poulticed while lying upon a 
pillow. 

^th. Left forearm examined ; callus apparently consolidating about the 
ulnar fragments ; no favourable change with the radial fragments. 

dtk. Some appearance of erysipelas about the left hand, with general 
febrile excitement. Patient ordered to be purged with blue mass and castor 
oil, and then put on quinine. 

isth. Patient's condition much improved; erysipelatous inflammation 
vanished ; left forearm put up in a starch bandage, as I determined not to 
repeat the drilling. 

16^7?,. Abscesses of right forearm have ceased discharging ; ulcers almost 
healed. 

July 30. Patient discharged by request, promising to return to the hos- 
pital in cooler weather, to submit to the operation of excision. His con- 
dition was very much the same as upon entrance. 

February It, 185*1. Nicholas Vanderwich was readmitted into the hos- 
pital. His health was robust, and his forearms in very much the same 
condition as when he was discharged. 

2lst. The patient was chloroformed, and longitudinal incisions, about 
three inches long, were made upon the radial and ulnar borders of both fore- 
arms, immediately over the false joints. The joints being fully exposed, the 
soft tissues about the bones were disturbed only sufficiently to allow of my 
passing the large curved and grooved resection sound successively under the 
different fragments, above and below the abnormal articulations; the section 
of the bones was made with the common amputating saw, only enough of 
each fragment being taken away to admit of good apposition of the op- 
posing extremities. The incisions were closed by sutures, supported with 
adhesive strips, and the arms put up with rectangular splints applied late- 
rally, as in fractures about the elbow. After the patient was put to bed, 
he was ordered: R. — Pul. gum opii gr. ij ; this to be repeated in three 
hours, if awake and in pain. 

2M. Patient had some febrile excitement last evening ; this now passed 
off, and he feels comfortable ; the forearms only a little sore; bowels con- 
stipated. Be. — Hydr. chlor. mite gr, v; pul. Doveri gr. x. Take in syrup 
at bedtime, and in the morning a dose of castor oil. 

24:th. The dressings were removed from the right arm, as patient com- 
plained of more uneasiness from this than the left ; wounds found to be 
suppurating a little. The sutures were cut away, and the member supported 
in a rectangular wire gutter, instead of the angular side splints ; this ar- 
rangement gave greater facility for examining the parts, and kept them at 
a lower temperature. Liberal diet of milk and beef-soup allowed, with a 
pint of porter per diem. 

Right arm dressed ; a good deal of suppuration from the super- 
ficial and deep tissues. 

21th. Both arms dressed. Left looking well ; sutures removed; union of 
wounds nearly complete, with very little suppuration ; wire gutter applied. 



140 KiNLOCK, Pseudartlirosis of Bones of Forearms. [Jan. 



28^7?. Right forearm much engorged ; diffuse suppuration threatened. 
Patient kept in bed ; limb to be coYered with lint, and irrigated with cold 
water. R- — Tinct. opii gtt. xx, every three hours; diet milk, ad lihitumy 
with pint of porter continued. 

llarch 1. Engorgement greater ; gangrene threatened. Free incisions 
made through the skin and fascia to relieve tension ; tinct. opii and porter 
continued, with a double dose of the tincture at bedtime ; diet same. 

4cth. Right arm looking better ; swelling somewhat subsided ; general 
febrile excitement much less. Water-dressing continued, and the tinct. opii 
diminished to gtt. x three times a day. 

Qth. Both arms dressed to-day. Left forearm looks remarkably well ; 
wounds healed without deep suppuration. Right forearm still improving; 
a small abscess discharging on the posterior aspect near the elbow ; same 
dressing and treatment continued. 

Wi. Right arm placed back into the angular gutter splint ; stop tinct. 
opii, and give at bedtime pul. Doveri, gr. x ; liberal diet, with porter, 
continued. 

Ibth. Right forearm again disposed to inflammatory action ; patient's 
bowels constipated. Splint removed, and member supported upon a pillow; 
cold water-dressing renewed ; ordered : R. — Pil. hydr. mass and ext. colo- 
cynth comp. aa gr. v in pil. No. 2. To be taken at once, and followed in 
three hours by a dose of castor oil. 

16^/1. Right forearm much better; abscess near elbow still discharging 
some ; wounds inclined to heal. 

20th. Wire splint reapplied to right arm. 

Mth. Both forearms look very well ; but no attempts at osseous union 
manifest in either. 

2dih. Patient now walks about, with both arms well secured with splints 
and bandages ; has best diet of the house, with porter continued. 

April 4. Left forearm examined ; ends of bones perfectly movable ; fric- 
tion of the ends resorted to, with the view of increasing plastic deposit ; 
splints reapplied. 

11th. Nothing like union detected in the bones of either arm. 

2Uh. Right forearm somewhat more inflamed ; superficial ulceration, 
with slight purulent discharge near the elbow. Ordered a dressing of tannin 
and glycerine to ulcer, and R. sul. magnesia .^ss, to be taken in water. 

30^7?. Right forearm much better ; left forearm healed ; no consolidation 
of the bones in either. 

May 22. Ulceration of right forearm entirely healed ; no union in either 
member. 

June 1. No improvement ; fragments much more movable than before 
operation ; patient discharged by request, as he was considered incurable ; 
directions were given as to the best mechanical support to be employed, in 
order to secure some degree of usefulness of the suffering limbs. 

Remarks. — The above are the details that I conceive important to the 
understanding of the case ; I have omitted many items in regard to varia- 
tions of treatment and diet, in order to economize space. I will say here, 
that at one time the patient was kept upon the phosphate of lime, but 
without perceptible result, so I have given no daily notes in regard to its 
use. As to the whole treatment, it was unsatisfactory in the extreme. It 
would have been better for the patient had he never entered the hospital 



1859.] 



Jackson, Obstinate Hemorrhage. 



141 



ward. Recent reports from the London hospitals lead us to expect very 
unsatisfactory results from the treatment of pseudarthrosis by any of the 
usual methods. The truth of this opinion is strongly corroborated by 
the above case. It appeared to me a remarkably favourable one for 
operation, and any surgeon must have experienced some disappointment at 
the successive failures of persevering efforts. The patient's robust health ; 
his great courage ; his manly endurance and astonishing patience, made me 
hopeful in the face of authoritative and discouraging opinion. Why the 
mere delay of union of a fractured bone for a few weeks or months, should 
dispose to such a change in the character of the nutritive acts of a part, as 
to lead to the abrogation of the beautiful law of analogous formation, is a 
mysterious problem, which science has not yet solved. Many of the ancient 
surgeons were so impressed with the danger of the operative procedures 
practised for the relief of this pathological condition, that they preferred 
non-interference. With a good many moderns, the question is only as to 
the degree of risk attending the several operations. If resection be the 
one most likely to give bony union, it is also thought by many to occasion 
most danger to life and limb. The advocates for the milder plans of 
operation, have, probably, been too hasty in fixing their value. It will be 
mortifying if modern surgery be compelled to abandon operative interfer- 
ence, not solely from the dread of dangerous consequences, but because of 
the utter impotency of art. We had hoped much from the procedure of 
Dr. Brainard, yet this is the second time that it has signally failed in our 
hands. True, the successive operations with the drill in the case just 
reported, were not practised at the precise intervals of time suggested by 
Dr. B. ; the complications of the case, and the results following some of 
the drillings, prevented a rigid adherence to Ms directions. But, neverthe- 
less, a very fair trial was given to the procedure, and it failed. We are 
not publishing the instance, however, with any view of condemning the 
operation. This would be premature, as the result proved that resection 
was attended with more danger to the patient, and was followed by as little 
success as the operations with the drill. We can only assume that in the 
case before us there was some radical defect in the nutritive acts of the bony 
tissue implicated, which, as before intimated, is not explicable in the present 
state of science. 



Art. XI. — Obstinate Hemorrhage following a divisioyi of the Frsenum 
Lingua. By A. Reeyes Jackson, M. D., of Stroudsburg, Monroe Co., 
Pennsylvania. 

Having occasionally seen reported in the medical journals, cases of fatal 
hemorrhage from the division of the frsenum linguae in children, I am iii- 
No. LXXIII.— Jan. 1859. 10 



142 Jackson, Obstinate Hemorrhage. [Jan, 

duced to relate the following ease, in which a very simple contrivance was 
entirely successful in checking the bleeding, after an operation of this kind. 

Some years ago I was called to see an infant, aged eight months, son of 

Mr. S , near White Haven, Pa., in consultation with Dr. H., under 

the following circumstances. Thirty-six hours previous to my arrival. Dr. 
H. had divided the frasnum linguae, and the wound had been bleeding ever 
since, all the efforts that had been made to check it having been unavailing. 
Dr. H. was not present when I reached the place, but in a note which he had 
left for me, he desired me to do what I could for the little patient, and stated 
that he had already used, unsuccessfully, cold applications, a variety of 
styptics, lunar caustic, the ligature, and the actual cautery. 

The child was already very greatly reduced, from loss of blood, which 
was continuing to ooze out from the cut edges of the wound. 

I procured from the father of the child (who was a deer-hunter), a few 
buckshot, and flattened two of them out into disks, or round plates, by 
means of a hammer, using the side of an axe as an anvil. I then pierced 
each of these through the centre, with a common sewing-needle. Then 
taking a piece of annealed silver wire from a double canula in my pocket- 
case, I tied a knot on the end of it ; and having split, with a pocket-knife, 
half way through another shot, placed the wire in the bottom of the slit, 
the sides of which were then firmly pressed together with a pair of tonsil- 
forceps, care being taken at the same time to draw the knot, on the end of 
the wire, close to the shot. The free end of the wire was then passed 
through the hole in one of the plates, which was drawn close against the 
shot. The other plate was now passed up to within a quarter of an inch 
of the first, and a second shot, previously split like the first, placed against 
it, but not pressed so tightly upon the wire, but that it could be moved with 
a moderate force. 

My instrument, which, it 'will be perceived, formed a clamp, was now 
ready to be applied, which was done in the following manner : — 

The father, having taken the child in his lap, and held its mouth forcibly 
open, I applied the instrument in such a way, that the whole of the cut 
frsenum was brought between the flat surfaces of the two plates. The 
second shot was now pressed strongly against the outer side of its corre- 
sponding plate by means of the forceps, and by pulling, at the same time, 
upon the free end of the wire. The plates were in this manner brought 
closely together, and were kept in their position by pressing together 
firmly, the split in the second shot. The bleeding was immediately con- 
trolled, and nothing remained but to cut off the end of the wire, close to 
the shot. 

The child was then allowed small portions of wine-whey, every two or 
three hours ; and, at the end of about twenty-four hours, when the clamp 
was removed, there was no return of the hemorrhage. 

I think, in case of emergency, the wire might be replaced with a piece 
of stout linen thread, although the former is certainly preferable. 



1859.] 



143 



REVIEWS. 

Art. XII. — 1. Hygiene, or Health as depending upon the Conditions of 
the Atmosphere ; Food and Drinks ; 3Iotion and Best ; Sleep and Wake- 
fulness; Secretions, Excretions, and Retentions; Mental Emotions, 
Clothing, Bathing, &c. By James H. Pickford, M. D. London : John 
Churchill, New Burlington Street, 1858. 

2. Papers relating to the Sanitary State of the People of England: being 
the Results of an Inquiry into the different proportions of Death pro- 
duced by certain Diseases in different districts in England. Commu- 
nicated to the General Board of Health by Edward Headlam Green- 
how, M. D., Lecturer on Public Health at St. Thomas's Hospital, and 
Physician to the Western General Dispensary. With an Introductory 
Report by the Medical Officer of the Board (Dr. John Simon), On the 
Preventability of certain kinds of Premature Death. Presented to 
both Houses of Parliament by command of Her Majesty. 

3. Ventilation of American Dwellings ; ivith a series of Diagrams, pre- 
senting Examples of different classes of Habitations. By David Bos- 
well Reid, M. D., p. R. S. E., &c. To which is added An Introduc- 
tory Outline of the Progress of Improvement in Ventilation. By 
Elisha Harris, M. D., late Physician in Chief to K York Quarantine 
Hospital, &c. K York: Miley & Halsted, 351 Broadway, 1858. 

The simultaneous appearance of these works, the first two trans, the 
other cis, Atlantic, is more than an intimation that the subject of public 
health, with its long train of important influences upon the condition and 
longevity of the human race, is attracting its deserved attention from the 
professional as well as general public in both hemispheres. The devoted 
attention which this subject is receiving, is the addition of another to the 
already long list of advancements which have marked the present as a won- 
derful age in the progress of human knowledge and improvement. The 
nineteenth century opened with a promise, in the great discovery of Jenner, 
of the further development of wonderful and glorious facts from the arcana 
of science. The promise was early redeemed by Sir H. Davy and John 
Dalton, who furnished the keys which unlocked the great storehouse of 
Chemistry, from which innumerable riches have been drawn. The applica- 
tion of steam as a propelling power both on land and sea, soon gave in- 
creased facilities of movement ; while, not to mention a host of other 
improvements of less striking, but scarcely less important character, the 
discovery of Photography, of Anaesthesia, and the application of electricity 
and magnetism to Telegraphing, by which finally a girdle is put about 
the earth in forty minutes," crown the present period as being the most 
wonderful in point of human progress that the stars, in their eternal 
courses, have ever witnessed. 

Amid these remarkable evidences of advancement, many of them the 
emanations of medically educated minds, great achievements are being made 



144 



Retiews. 



[Jan. 



in the cure of diseases and the prolongation of life, and the subject of pre- 
ventive medicine has not remained entirely unheeded or undeveloped. 
Many of the old scourges of our race, which were once deemed inevitable as 
death, have been demonstrated to be absolutely and entirely preventable 
and unnecessary. For example, it is but as yesterday that John Howard 
published to the world the astounding condition of the prisons of Europe, 
which showed, to use his own phrase, how full of emphatical meaning is 
the course of a severe creditor, who pronounces his debtor's doom to rot in 
gaol;^^ but where now shall we find an instance of jail femr% So too 
Hcurvy, the sailor's scourge (by which Anson, in his celebrated voyage of 
1740-2, lost within the first ten months nearly two-thirds of his crew, and 
during the remaining period about half the survivors ; and of which dis- 
ease there were admitted into Haslar Hospital, in 1780, 1457 cases.) 
Scurvy is now never seen by one physician in a hundred, and in fact occurs 
only mnder the most peculiar and accidental circumstances, so well has its 
prophylaxis come to be understood. In this category we might include 
several other instances, but we forbear, as the theme has been dwelt upon 
at length by abler pens. We merely advert to the topic to show that me- 
dical minds have not been altogether indifferent to the true spirit of their 
mission ; at the same time, it is but due to justice to declare the opinion, 
that the profession has not exerted itself to the full extent that it should, 
in the matter of general preventive medicine. Too much absorbed in the 
pursuit of a living to enable them to turn from the treatment of individual 
diseases to the public service of their prevention, and alas ! that it must be 
said, suffering too much from the prevalence of quackery, the public health 
has correspondingly suffered. But this opprobrium is rapidly wearing 
away, when such as they whose names appear on the title pages above 
quoted — names which have already become worthy of regard as labourers 
in the walks of chemistry, pathology, physiology, and general medicine — 
v/hen such persons are seen to enter this new field, and to put forth their 
energies for the development of its fruits, then we may rest assured that the 
work will be carried forward until all that can, will, in due time, be accom- 
plished. And it behooves every member of the profession to see that he is 
no laggard in the road towards a full knowledge of the science of public 
hygiene, even though he may not choose to engage in its practical applica- 
tion ; for the time is rapidly approaching when the suppression of every 
health-impairing circumstance will be demanded by the public voice, and 
the medical practitioners of every vicinage will be the authorities for magis- 
terial action. How important, then, that every one should be fully. pre- 
pared to render a correct and intelligent judgment upon everything apper- 
taining to the subject. 

The three works before us belong to three several branches of the sub- 
ject ; the firat to its philosopJi.y, and the elucidation of the great natural 
causes which influence human health for good or for evil ; the second 
(which has not yet been publicly issued, but with a copy of which we have 
been politely favoured in anticipation, by the distinguished author of the 
Introductory Report) is an elaborate and valuable document, the result of 
great labour and research among the death returns of England ; and the 
t/d7-d, from the pen and pencil of the distinguished Edinburgh (now of N. 
York) chemist and hygienist, is an exposition of the various modes by 
which the principles of domestic ventilation may be effectively carried out 
in ])ractice. 

The worl: of Dr. Pickford comes very d^iropos to supply a great deside- 



1859.] 



PiCKFORD, Greenhow, Reid, Hygiene. 



145 



ratum to the student of hygiene — a condensed summary, in manual form, of 
the great facts relating to it. The discussion of its natural laws and prin- 
ciples have heretofore been scattered through numberless volumes, which 
have required the greatest toil and difficulty to collect together upon any 
one branch. The author's aim has been to present to his professional 
brethren, to the medical student, and to the public at large, a faithful tran- 
script of accurate research, observation, and experience, a statement of facts 
and admitted truths, together with such inferences and deductions as ap- 
pear warranted and demanded. 

Very copious authorities have been consulted, and where differences in 
statements or opinions occur, they are placed in juxtaposition, so that the 
reader may draw his own inferences, or exercise his own experimental 
knowledge on the subject, while the very abundant references will enable 
every one to read more at length on any branch of the subject treated of. 
ThQ fir Ht part, which alone is before us, treats of the physics of the atmo- 
sphere, the seasons, temperature, rain, winds, and pressure ; the respiration 
of plants and animals, the circulation of the blood, the chemistry of respi- 
ration, and animal heat ; infection, contagion, malaria, sewerage, drainage, 
ventilation, and climate in connection with disease. 

The second and third parts, which are to follow, will embrace the other 
branches of the main subject. 

jSTot only is the present volume copiously indexed, but its paragraphs 
are numbered successively from the beginning to the end, there being 1375 
in all. 

To exhibit more clearly the character and style of this timely and excel- 
lent work, we extract a few of them. 

"110. Atmosplieric Tides. — The atmosphere has its tides and currents like 
those of our great oceans. These are apparently of two kinds ; the one the result 
of the heat of the sun's rays, the other of the attraction of the moon. 

"111. Throughout the world there are two daily atmospheric tides. Within 
the tropics the flow of the atmospheric tide, according to Humboldt, takes place 
with the greatest regularity at 9 or 9|- A. M,, and at 10 or lOf P. M. ; and the ebb 
at 4 or 4^ P. M., and at 4 A. M. The latter is attributed to the expansion of the 
air during the hottest part of the day ; the former to the pressure of the masses 
of cool air. 

" If the height of these tides be proportionable to the difference between the 
specific gravity of air and mercury, the morning tide will be about 13 feet, and 
the evening tide 25 feet." 

"331. Ozone (from o^co, to stink). — This is one of the ingredients of the atmo- 
sphere, the discovery of which was claimed, in 1848, by Professor Schonbein, of 
Basle. A reference, however, to pages 342, 343, of Dr. Prout's Brtdgewater 
Treatise, published in 1834, and to pages 569, 570, of the appendix of the same, 
will show that he had already discovered the existence of this compound, which 
he believed to be ' analogous to, if not identical with, the deutoxide of hydrogen.' 
Dr. Prout was of opinion ' that the excess of oxygen above the amount of 20 per 
cent, which there ought to be in the atmosphere, if its composition were, as there 
can be little doubt that it is, determined by the law of chemical proportions, be- 
comes associated with the vapour of the atmosphere, and forms a deutoxide of 
hydrogen. The oxygen and vapour in this combination, says Dr. Prout, are 
feebly associated and appear to be separated by the slightest cause. 

"332. Ozone is a teroxide of hydrogen, consisting of three atoms of oxygen= 
16x3=48, and one of hydrogen=l . 

" 333. Schonbein believes ozone to be a regular constituent part of free atmo- 
spheric air, inappreciable though varying in quantity, and to be everywhere 
incessantly and naturally formed out of atmospheric oxygen, in consequence of 
ekctrical discharges constantly taking place in the air. 



146 



Reviews, 



[Jan. 



" De la Kine and Berzelius consider ozone to be nothing but allotropized 
oxygen. 

" Scoutetten defines ozone to be oxygen positively electrified." 

"334. Ozone, says Schonbein, is the most powerful oxidizing agent we yet 
know of, transforming, in the cold, even silver into the peroxide of that metal, 
iodine into iodic acid, nitrogen (a strong base being present) into nitric acid. The 
' — ous' acids into ' — ic acids, the * — ites' salts into ' — ates' salts, the metallic sul- 
phurets into sulphates. 

"335. Ozone destroys instantaneously sulphuretted, seleniuretted, phosphor- 
etted, ioduretted, arseniuretted, and stibiuretted hydrogen, oxidizing their con- 
stituent parts. 

" 336. Schonbein has demonstrated ozone to be one of the chemical antipodes 
and antidotes to all oxidable miasmatic and malarious gases and emanations dis- 
engaged from putrefying animal and vegetable substances, converting them into 
innocuous matter, and thus purifying and sustaining the entire salubrity of the 
atmosphere. In short, so hostile to organic miasmata, so incompatible with them 
is ozone, that the presence of the latter enables us to affirm the absence of the 
former, and the healthiness of the locality in which it is found. 

" 337. Ozone is produced in large quantities over lands covered with luxuriant 
vegetation, and over water. 

" 338. Ozone is found in abundance on the sea-coast, and on mountains and 
elevated localities ; yet, in reality, it does not progressively increase in quantity 
in the ratio of elevation. But its diminution or absence in the lower atmospheric 
strata, depends on its destruction by miasmatic emanations, with which it has 
come in contact, and which it has decomposed and made inert. 

" 339. When the mean amount of ozone indicated by the ozonometer on the 
sea-coast, at an elevation of 85 feet, was 2.2, it amounted inland, at the same 
elevation, to 0.6 ; at 170 to 1.3, and at 225 feet to 3.8. 

"340. Ozone, like the deutoxide of hydrogen, is remarkable for its bleaching 
properties. Its presence is more strongly marked during the night than in the 
day. 

"341. Pure ozone, perhaps on account of its exalted oxidizing powers, is a 
most powerful poison, and when inhaled into the lungs, even in minute doses, 
produces deleterious effects, and in large doses quickly destroys the strongest 
animal life. 

"342. The inhalation of ozone produces great acceleration of the respiration, 
a painful constriction of the chest, not unlike asthma, spasm of the bronchial 
tubes, violent cough, irritation and inflammation of the mucous lining of the 
bronchiae and air-passages, catarrhs, coryza, possibly hay fever, intense pneumo- 
nia, &c. 

"343. MM. Scifferdecker and Bockel, probably on insufficient data, believe 
there is no connection between ozone and bronchitis, pneumonia. 

"344. Drs. Moflfatt, Schonbien, and Scoutetten, are of opinion that a proper 
admixture of ozone and atmospheric air exercises an important influence on the 
animal economy, and is indispensably necessary to the due accomplishment of 
all the vital functions, and to the relief and modification of disorder and disease. 

"345. In confined places where ozone cannot penetrate, plants and men be- 
come blanched ; the skin grows pallid, the blood loses colour, lymph predomi- 
nates, all the tissues soften, and serious diseases of the adynamic type break 
forth. 

" 346. The presence of ozone in the atmosphere or water is readily detected by 
test paper prepared by saturating strips of white bibulous paper in a mixture 
made by boiling one drachm of white starch in an ounce of distilled water, for 
three minutes, in which are to be dissolved, when cold, twelve grains of chemically 
pure iodide of potassium. The discoloration of paper, thus prepared, to brown, 
on exposure to the atmosphere, and to purple, when immersed in water, indicates 
the presence of ozone ; the degree of discoloration, its intensity and amount. The 
change of colour is owing to the oxidation, by the ozone, of the potassium of the 
iodide, and by the combination of the iodine, thus set free, with the starch, to 
form an iodide of starch." 

" 573. South winds are highly ozoniferous, and probably on this account, pro- 



1859.] 



PiCKFORD, Greenhow, Reid, Iljgiene. 



U1 



diice catarrhs and bronchitis. They soothe and allay a dry and irritable condi- 
tion of the mucous surfaces of the air-tubes and cells, and greatly alleviate the 
sulFerings, and indefinitely prolong the existence of the phthisical patient." 

In the following paragraphs are set forth facts of great importance, not 
only in the treatment of diseases, but we commend the statements particu- 
larly to the attention of the keepers of some prisons we wot of, in which, 
the punishment by flogging having been declared illegal, resort has been had 
to the not less cruel and far more dangerous infliction of the sJiower-bath: — 

" 758. The pulse may be reduced 50 beats in the minute, and may be rendered 
irregular and quite imperceptible, by the long-continued action of cold water on 
the surface of the body. 

" 759. A shower or douche bath, delivering per minute 30 to 40 gallons of water 
at 64P or 68^, will occasion the immediate depression and reduction of the pulse 
to this extent. 

" 7G0. A shower-bath of eight gallons only, at 47^^, reduces the volume, but does 
not affect the frequency, of the pulse. At 14P or 110° no perceptible effect is 
observed." 

"T7ie Glucose Function of the Liver. 

"832. It may not be altogether irrelevant to the subject under consideration 
to allude to the original and important discovery which has within the last few 
years been made by Prof. Claude Bernard, the successor of Magendie, with refer- 
ence to the functions of the liver. This gentleman has ascertained that the liver 
in man and mammals secretes a saccharine matter — glucose — which is conveyed 
from the secreting cells, by the inter-, intra-, and sublobular veins, to the venae 
cavae hepaticae, and thence, in the course of the circulation, to the vena cava in- 
ferior and right auricle of the heart, and by the pulmonary arteries to the lungs, 
where it is burned, thereby contributing to the sustentation of animal heat. 

"833. M. Bernard, after repeated experiments and the most careful investiga- 
tions, could not detect sugar in any other portion of the circulating system, and 
he therefore felt himself justified in asserting that sugar is a normal product of 
the liver, and that the saccharine matter so secreted cannot be detected in health 
in any secretion, vessel, organ, or tissue of the body, other than in the blood of 
the veins above mentioned, and in the substance of the liver itself." 

"837. But even admitting, for the sake of argument merely, that sugar has 
been found in the chyle, this neither invalidates nor detracts from the importance 
of M. Bernard's discovery that the liver secretes, separates, or eliminates a vege- 
table substance [glucose) from animal matter alone, or from both combined ; nei- 
ther does it disprove his statement that the substance so produced assists, by its 
combustion in the lungs, in sustaining animal heat. It might, if satisfactorily 
established, tend to show that even glucose may have its antecedents. 

"838. Apart, however, from the interest which attaches to this discovery in a 
physiological point of view, it originates questions of the gravest import both to 
the pathologist and to the physician. 

" 839. If the quantity of saccharine matter secreted or separated be not entirely 
burned in the lungs, the surplus will circulate in the system, to be eliminated by 
the kidneys as diabetic urine. 

" 840. The question therefore arises, whether, in seeking for the cause of dia- 
betes, we should not look to impaired, defective, or embarrassed respiration, 
rather than to a faulty or perverted action of the assimilating organs, or of the 
kidneys themselves ; and whether, in the treatment of this disorder, we should not 
suggest such measures as may contribute to the increase, where possible, of the 
respiratory functions, if these be in defect, and, as a consequence, to a larger con- 
sumption of the glucose. 

" 841. Sugar has been constantly found in the urine of those whose respiration 
had become enfeebled by age. 

"842. Again, if the liver, from disorder or disease, fail, either partly or alto- 
gether, in its glucogenic, as is constantly the case with its biliary, function, the 
question may arise whether the saccharine matter — or, rather, the substance cir- 



148 



Reviews. 



[Jan. 



culating with the vital fluid, whence the glucose is derived, separated, or elimi- 
nated — may not be capable of inducing disorders other than diabetes." 

The following definitions of two important terms we think will be well 
regarded : — 

" 910. By infection we understand a contaminated condition of the atmosphere, 
by pestiferous miasmatic emanations from the earth's surface, by poisonous gas- 
eous exhalations, the product of putrefactive changes of organic or vegetable 
substances, or by both combined, capable of tainting, polluting, or con^upting 
the body. 

"911. Infection is a local taint of atmosphere originating without the body. 

"912. Disorders produced by malaria, as intermittent, remittent, and yellow 
fevers, are not communicable by the sick to the healthy. 

"913. By contagion ^Q, understand the transmission of an infectious malady 
from the sick to the healthy by pollution of the atmosphere by the eflSuvia or 
emanations from or by the exuviae of their bodies, or by means of fomites im- 
bued with the poison; or by immediate or mediate contact. In the latter case 
the humidity of the atmosphere becomes a medium of contact. 

" 914. It seems to be a general law of animal nature, at least among the mam- 
malia, that the accumulation and stagnation of the exhalations of the living body 
produce disease. The glanders of the horse arise only in stables where a large 
number of horses are stabled, and the distemper of dogs in kennels. During the 
American war it was proposed to send live sheep from England across the At- 
lantic. In a few weeks, in consequence of being crowded on shipboard, they all 
died of a febrile disorder. 

"915. Contagion may therefore be designated a specific virus originating 
within the body. 

" 916. A contagious fever or disorder is produced by an animal poison, and 
not by malaria." 

Of the laws of malaria, our author speaks thus : — 

"932. We have already seen that a healthy adult respires 20 times in a 
minute (844), and takes into his lungs at each inspiration 20 cubic inches of air, 
or 576,000 cubic inches in 24 hours (852), and that this respired air comes in 
contact, at each inspiration, with 201,600 square inches of mucous surface of air 
passages and cells (682) ; is it therefore matter of surprise that atmospheric air, 
contaminated by infectious or contagious matter, or poisoned by malarious, mias- 
matic, or paludal emanations, should exert its baneful influence on the blood, and 
on the organic nervous system through the nerves distributed to the enormous 
superficies, with which it comes in contact at each inspiration ? The wonder is 
that any of us escape. Indeed, where the percentage of contamination is large, 
few do escape. The history of the plagues and pestilences with which this and 
other countries have been visited during the last few centuries, fully bears out 
this position. 

" 933. Dr. W. Furgusson states that the African and the Creole are in a de- 
gree exempt from, and very rarely amenable to, those influences which generate 
in I^uropeans intermittent, remittent, or yellow fever. 

" 934. The precise nature of marsh effluvia has not yet been determined, 
though the most able analytical chemists and microscopists have devoted much 
time and attention to its investigation. Notwithstanding our ignorance of its 
chemical and physical properties, there is every reason to believe it to be an 
organic compound, composed chiefly of hydrogen and carbon, abundantly disen- 
gaged from the earth's surface by the solar rays, and diff'used during the day 
through the atmosphere, and to be precipitated, after sunset, in a condensed 
form in proportion to the diminution of temperature." 

" 956. The specific gravity of malaria is considerably greater than that of the 
atmosphere." 

" 959. Malaria, in consequence of its great specific gravity, is found in its 
utmost intensity in valleys, intermingled with mists and fogs ; on the earth's sur- 
face combined with the aqueous vapour of the atmosphere ; entangled and stag- 



1859.] 



PiCKFORD, Greenhow, Keid, Hygiene. 



149 



nant in the coarse vegetation of the jungle of the East ; in the dank grass, strong 
weeds, and dense brushwood of the West Indies ; at the bottom of moats and 
ditches surrounding fortified towns ; on the ground floors of our dwellings, and 
in underground apartments. 

" 960. In all malarious districts and seasons the inhabitants of ground floors 
are uniformly affected in a greater proportion than those of upper stories. Ac- 
cording to official returns, the proportion of those attacked in the lower apart- 
ments of the barracks at Barbadoes exceeded that of the upper by one-third.'' 

The subject of public hygiene, or State medicine, which is now engaging 
so much attention, receives powerful aid from our author, but we have 
room only for the following quotations on this subject : — 

" 1028. In all large cities and towns there are plague spots where fever of the 
intermittent, remittent, or continued form always prevails in greater or less in- 
tensity. There are districts or locations in our modern Babylon which are ever 
emitting the poison which generates typhus fever ; there are certain squares and 
streets, nay, particular houses, the inmates of which, family after family, for a 
long series of years, have been the victims of typhus fever, though the districts 
in which they are situated are airy, and the soils dry." 

" 1030. There is probably no subject so complex, so incalculably difficult to 
grapple with, especially if it be how to apply a remedy, as the drainage and 
sewerage of large overgrown cities. Yet we must perceive that unless this be 
efficiently done, an ultimate limit is set by the hand of man himself to dynasties, 
to peoples, and to nations. The air we breathe, loaded with carbonaceous mat- 
ter, sulphurous and sulphuric acid, sulphate of ammonia, and sulphuretted hy- 
drogen, is deprived by the absence of vegetation of the revivifying principle, 
oxygen, and is hence less fitted for the necessary changes of the blood effected 
during respiration. The earth which we tread under our feet, loaded with the 
ashes of our forefathers, and rich with the remains of animal and vegetable mat- 
ter of ages long gone by, saturated with the putrefying contents of myriads of 
cesspools and leaking sewers of our own day, emits at certain seasons of the 
year the poisonous emanations which generate typhus, diarrhoea, dysentery, and 
cholera ; whilst the waters of our principal tidal rivers, converted into open 
common sewers, teem with pestiferous exhalations, charged with the germ of 
disease, or the messenger of death. If, under these favouring conditions, a pes- 
tilential epidemy invade our shores, it finds us an unprepared and easy prey. 

" 1031. The government of every State would do wisely to appoint a Minister 
of Public Health, whose duty it should be to superintend and watch over the 
public health of the community at large, to see that due ventilation is observed 
in all large and public buildings, and in the dwellings of the poor ; to ascertain 
that the water is pure and its supply ample ; to prevent all noxious and un- 
wholesome trades and manufactures being carried on within a certain distance 
of towns or dwellings ; to prohibit intramural burial grounds, slaughter houses, 
and slaughtering cellars ; but, above all, to lay down and carry out an effectual, 
efficient, complete, and common sense plan of drainage and sewerage for every 
town and city." 

" 1055. The bed of the river Thames, at London, is estimated approximately at 

108,900 

2,245 acres; therefore 2.5x43,560 = 108,900 cubic feet and ^ ^^^^ — 678,505 

gallons of ivater evaporated in one year from one acre of water ; which gives 
108,900x2,245 = 244,480,500 c^^5^c/ee^ = 1,523,242,991 gallons evaporated an- 
nually, or 4,170,000 gallons, or about 18,000 tons of water raised daily from the 
surface of 2,245 acres of the polluted Thames at London, and diffused through 
the atmosphere of the city and neighbourhood. 

" 1056. During calm, clear weather, these emanations, consisting of sulphuret- 
ted and carburetted hydrogen gases, of nitrogen and carbonic acid gas, free am- 
monia, and other vapours, ascend high into the atmosphere, where they are 
generally diffused ; but on their descent, on cooling, they spread broadcast the 
seeds of disease and death ; but during cloudy, moist weather, and particularly 
during calms, and the colder air of night, they are condensed into haze, mist, or 



150 



Reviews. 



[Jan. 



fog, and occupy the lowest districts, the inhabitants of which are the earliest and 
most numerous victims." 

" 1060. It may be laid down, if not as a law, at least as a general rule, that 
when the temperature of the waters of a river in a state of putrefactive foulness 
exceeds 60° Fahr., the minimum temperature of the atmosphere being below 
this, diarrhoea and cholera will ensue, and will continue to increase in amount 
and severity in the direct ratio of the increased temperature ; and that when the 
temperature of the water of the river falls below 60*°, so will these disorders 
begin to decline, and will cease altogether." 

" 1075. From experiments instituted by Schonbein, it appears that atmospheric 
air, containing but ^-^^o ot) o ozone is capable of disinfecting its own volume 
of air loaded with the miasmata given off in one minute by 4 oz. of flesh in a 
high state of putrefaction. 

" 1076. Atmospheric ozone in destroying oxidizable miasmata suffers destruc- 
tion in its turn. This is one of the reasons why azone, though continually en- 
gendered, cannot accumulate in the atmosphere to an extent which would be 
prejudicial to animal life." 

" 1083. Mr. Condy, of Battersea, has recently introduced to the notice of the 
profession and the public a disinfectant fluid, of which the chief constituent is 
' condensed oxygen' It is said not only to deodorize and disinfect perfectly, 
but also to destroy absolutely the cause of infection. It possesses a most im- 
portant advantage over chlorine, that it is not poisonous, does not evolve any 
obnoxious or unpleasant smell, and may be employed to purify water. In short, 
it is a near approximation to ozone, and promises entirely to supersede chlorine 
as a disinfectant. It is favourably noticed by the Board of Health as " a true 
disinfectant.''^ 

" 1149. Dr. Eoscoe has shown that the beneficial action of the hriclc and mor- 
tar lualls of our dwellings is not confined to the mere absorbing from, or restor- 
ing moisture to, the atmosphere, but that it extends to a very large diSusive 
interchange between the carbonic acid gas of the apartments and the external 
atmosphere; that, in fact, brick walls are powerful aids to ventilation. Dr. 
Roscoe ascertained, that in a closed space, the air of which contained 16 per 
cent, of carbonic acid gas, 3.25 per cent, escaped through the solid brick. 

" 1150. The unhealthiness of iron, or new and damp houses, is probably partly 
accounted for by the absence of all diffusive interchange through iron and wet 
walls. 

"1151. Newly built houses, and houses how long soever they maybe built, 
though exposed for years to the action of dry air, are unhealthy when first in- 
habited. The lime of the dry hydrate of the mortar of their walls combines with 
the carbonic acid abundantly supplied by the lungs and skin of their first oc- 
cupants, and parts with and sets free as moisture the 24 per cent, of water che- 
mically combined with it. The water thus displaced speedily evaporates and 
saturates the atmosphere of the various rooms, its excess being condensed on the 
windows and cold walls. 

" This does not depend on ordinary moisture or dampness of the walls, but on 
the retained water of the hydrate, and must invariably occur on the first occu- 
pancy of any building into the walls of which lime enters as a component." 

"1154. In any and every case the ample and free admission of fresh air and 
the complete and ready escape of the contaminated atmosphere, are all that can 
be desired or attained. If we err, better that we err with too much than too 
little pure air. Air is not less the food of man than the daily bread on which he 
feeds. An impure or vitiated state of the atmosphere of his dwelling is infinitely 
more injurious to the general health and vigour of body than would be the most 
unwholesome and corrupt food and drinks." 

The second work on our list : The report of Dr. Greenhow, is a valuable 
exposition of the ratio of deaths per 100,000 of the population, from 
certain causes which are believed to be either wholly or partially prevent- 
able; and the extraordinary differences which exist in this ratio, in different 
districts, afi'ord an illustration against which there can scarcely be a cavil, 



1859.] 



PiCKFORD, Greeniiow, PvEID, Hygiene. 



151 



that various hygienic circumstances do exert potent influences in increasing 
and diminishing the amount of disease and death. This is, indeed, the 
idea which it has been his aim to establish, or rather it is the conclusion to 
which his researches decidedly point. 

As a specimen of this, we quote from Dr. Simon's able introduction to 
the report : — 

"In the subjoined figures you can read at a glance that vast range of their 
local death-rates which Dr. Greenhow has the merit of having made evident 
for public information. 

"1. Annual death-rates, hy diseases which are either ivholly, or almost wholly, 
preventable, under good sanitary arrangements, have ranged in different dis- 
tricts as follows : — 



Cholera. 


Diarrhoea and 
dysentei'y. 


Continued fever. 


SmaUpox. 


From notliing 


From 4 


From 21 


From notliing 


to 


to 


to 


to 


403 


345 


209 


146 



"2. Annual deatJh-rates, hy diseases which, to some considerable extent, are 
inevitable, but of which the severity or the frequency may be controlled by good 
sanitary arrangements, have ranged in different districts asfoUoivs : — 



Tubercular 

phthisis 
in women. 


Non-tubercular 
lung diseases 
in men. 


Common infectious 
disorders of 
childhood. 


Convulsive dis- 
orders of 
childhood. 


Pulmonary 
affections of 
childhood. 


From 229 


From 66 


From 694 


From 280 


From 213 


to 


to 


to 


to 


to 


588 


869 


2149 


3832 


2897 



Drom the first of these tables (we repeat the general statement that the 
reader may see the full force of the fact and the argument), we learn that 
in one of the registration districts of England, within a certain period, 
only four deaths in each 100,000 of the population occurred from diarrhoea 
and dysentery, while in the same period, in another district, there occurred 
the proportion of 345 deaths from the same diseases. In the case of small- 
pox, there were, in some districts no deaths, while in one there were 146, 
for each 100,000 of the population. With regard to this latter disease, 
we have not the slightest difficulty in arriving at a conclusion as to the 
reason for this wide difference between the two districts from which the 
figures are taken — that the total exemption in the one case was due to the 
care exercised in extending vaccination, and to the avoidance of contamina- 
tion, and in the other to the neglect of one or both these precautions. 

Take another example, and hear the explanation of Dr. Simon. 

" Ee verting once more to the gross mortality due among young children to 
the conjoint action of those three classes of disease which I have now separately 
spoken of" [convulsive or nervous disorders, diarrhoea, and resipiratory inflam- 
mations, which destroy every year about 72,000 children, and occasion about a 
sixth part of the total mortality of England), ''I believe that the vast range of 
that aggregate mortality in different districts is due to the varying prevalence 
cf t'wo local causes : First, to differences in degree in common sanitary defects 
of residence ; some places abounding more than others in the foul air and foul 



152 



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[Jan. 



water of undrained, unpaved, unscavenged, unwashed, unliglited, unventilated 
localities and houses ; and, secondly, to occupational differences among the in- 
habitants ; there being certain large towns where women are greatly engaged in 
branches of industry away from homes ; where, consequently, those homes are 
ill kept ; where the children are little looked after ; and where infants, who should 
be at the breast, are improperly fed or starved, or have their cries of hunger and 
distress quieted by those various fatal opiates which are in such request at the 
centres of our manufacturing industry." 

With these brief examples of the striking manner in which this great 
subject is handled by the able author of the Introductory Report, we are 
prepared to look into the matter and manner of the paper of Dr. Greenhow, 
on which it is based. Of the circumstances which led to his investigation 
he speaks thus : — 

"No systematic endeavour, of which I am cognizant, has ever been made to 
investigate critically the causes of death in unhealthy places, and to refer the 
diseases which swell the death rolls of such places each to its special cause. 
Even the kind of diseases which most prevail in unhealthy places is imperfectly 
understood." * * * "Just as the excessive mortality of unhealthy towns has, 
upon inadequate proof, been referred to a few of the more prominent evils con- 
sequent upon the aggregation of men into urban communities, so likewise have 
the diseases that occasion this mortality been hastily inferred from data equally 
conclusive. The incongruous class of diseases, to which the term zymotic has 
been applied, is commonly spoken of, even by medical sanitary authorities, in 
such terms as to convey the impression that it comprises the diseases that are 
essentially preventable. The term zymotic is, indeed, often employed almost, if 
not quite, in the sense of preventable. It cannot, indeed, be doubted that cer- 
tain diseases comprised in the zymotic group are, like ague, produced by causes 
that are in their nature removable ; that others, as cholera and fever, derive at 
least the conditions of their malignant development from the filthy accumula- 
tions common in the neglected portions of large towns ; that a third class, which 
are propagated by contagion, find circumstances favourable for their propagation 
amidst the crowded population of cities ; or, lastly, that contagious and epidemic 
diseases find a class of persons incapable of successfully battling with illness, 
amidst the unhealthy and vitally-depressed inhabitants of unhealthy places. But 
these opinions have never been brought to the test of a sufficiently extensive 
investigation of facts." * * "We have thus still much to learn, both as to the 
nature of the particular diseases which produce the successive mortality of un- 
healthy places, and of the circumstances under which such diseases arise. * * * 
The importance of this question was forced upon my attention two years ago. 
The authorities of St. Thomas's Hospital, determined to found a lectureship on 
public health. The subject was one which had attracted much notice during 
several years, and had just at that period gained additional importance from the 
appointment of medical officers of health for the metropolitan districts, as well 
as for many provincial towns. 

"The council of St. Thomas's did me the honour of appointing me to the 
office ; and it was in the preparation of my first course of lectures that I first 
became fully aware of the vague and imperfect nature of the information upon 
which the sanitary agitation of the preceding twenty years had been based. 
* * * The broad and striking differences of death-loss in different places which 
had hitherto formed the staple topics of sanitary discussion, however valuable 
as a means of measuring the condition of the public health, afford no direct in- 
formation as to the causes that modify it; * * of what use to point to the fact, 
that the inhabitants of large towns often die twice as fast as those of country 
places, unless the diseases of which they perish , and the causes of those diseases, 
could likewise be indicated P and such information had never been procured." 

England and Wales have been divided into six hundred and twenty-three 
districts for the registration of births, marriages, and deaths. Some of 



1859.] 



TiCKEORD, Greeniiow, Reid, Iljgiene, 



153 



these consist of towns only; others are of a rural character altogether; while 
in other cases, a town forms a centre, and a considerable portion of sur- 
rounding country is comprised in the district. Dr. Greenhow's investiga- 
tions have extended to one hundred and five of these registration districts, 
and the time embraces the seven years from 1848 to 1854, inclusive. This 
period of time was chosen because it seemed to afford a sufficiently extensive 
basis to obviate the fluctuations that are liable to occur from year to year, 
and the census was taken in the middle year of the term, viz., 1851. The 
death-rates have been calculated in each district for 100,000 persons; for 
although it is true very few districts contain that number of each sex, and 
the entire population in most districts falls short of it, no real objec- 
tion exists against that standard, provided only the correct proportions be 
allowed. 

The several diseases which constitute the burden of his investigation are 
arranged in ten groups, namely : A. Pulmonary affections, b. Contagious 
diseases, c. Alvine flux. d. Typhus and erysipelas, e. Croup, influenza, 
and ague. r. Strumous diseases, g. Nervous diseases of children, h. Apo- 
plexy and paralysis, i. Kheumatic fevers and rheumatism, k. Carbuncle 
and phlegmon. 

The 105 districts included in the investigation were selected on account 
of each possessing some peculiar character, either of position, of salubrity, 
or of occupation, and are believed to afford a fair indication of the valuable 
results that may be expected to follow from a more extended and minute 
investigation. 

We have not space to follow Dr. Greenhowto much extent in this article, 
and must content ourselves with extracting a few of the more prominent 
results obtained by him, recommending the whole paper to the careful study 
of medical men (if happily it should ever be within their reach), as a model 
for similar investigation elsewhere, and as exhibiting the great value of a 
complete system of registration. 

Liverpool is ascertained to be the most unhealthy town in England, its 
annual average mortality being at the rate of 36 in the thousand ; Glendale 
is one of the healthiest rural districts, the deaths being only 15 in the thou- 
sand. The same ratio holds with respect to deaths from pulmonary dis- 
eases, the deaths by this class being 216 per 100,000 in Glendale, and in 
Liverpool 1,000 per 100,000, so wide is the gulf between the salubrity of 
these two districts. These are the extremes of the districts in point of sa- 
lubrity, while the remaining 103 districts occupy intermediate positions. 
" Glendale presents, perhaps, a standard of health impossible of attainment 
for the whole kingdom; Liverpool illustrates the great necessity of employ- 
ing some energetic and well devised means for improving the public health." 

The industrial occupations which have an influence upon the mortality 
of the several districts are classified by Dr. Greenhow as follows: 1. Agri- 
culture. 2. Commerce and maritime pursuits. 3. Mining. 4. Manufacture 
of metals. 5. Manufacture of earthenware. 6. Manufacture of textile fa- 
brics, t. Manufacture of shoes. 

Each of these classes receives special attention, and copious interesting 
tables give evidence of the faithfulness with which the investigation has 
been prosecuted, as well in relation to the influence of each upon the health 
of the two sexes, as upon the general population, giving abundant and 
unmistakable proofs of the immense losses suffered by both individuals and 
the State, by the neglect of sanitary measures, and furnishing distinct 
grounds for the continued study of public hygiene, and the enactment of 



154 



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[Jan. 



positive law for its practical application. We cannot better conclude this 
branch of our review than in the burning eloquence of the "conclusion" of 
Dr. Simon's Introduction: — 

''These questions are not uninteresting to the rate payers of places where high 
death-rates prevail. For sanitary neglect is a mistaken parsimony. Fever and 
cholera are costly items to count against the cheapness of filthy residences and 
ditch-drawn drinking-water. Widowhood and orphanage make it expensive to 
sanction unventilated work-places, and needlessly fatal occupations. * ^- * ^ 

"But if the subject may justly claim to be considered by the government and 
the legislature of this country, it is on higher grounds than those. The sacred- 
ness of human life against unjust aggression, is the principle above all others by 
which society subsists. To have realized this principle in law and government is 
the first indication of a social state ; and in any community pretending to be 
civilized, the failure of protection for life has ever been felt as a public scandal. 

" But growing knowledge must bear its fruit. It has now been fully recognized 
that with the very centres of civilization controllable influences are working 
against human life more cruelly than brute violence ever worked in the first dis- 
cordant beginning of society. It has been shown that in certain districts of Eng- 
land the operation of those controllable causes is vastly more powerful than in 
others ; that within the rule of certain sanitary authorities, particular forms of 
disease undergo a multiplication — a fivefold, and a tenfold, and hundredfold 
multiplication, of their lowest familiar fatality. 

" To supj)ose that such sanitary authorities could permanently disavow an in- 
terest in this knowledge, or that public opinion could long hold them irresponsible 
for so monstrous a waste of life, would be to misunderstand the meaning of civil- 
ization, or to belie the humanity of England y 

In his Introduction to the work of Prof. Keid, the last which we have 
now to notice, Dr. Harris lays down a postulate thus 

"The homes of the people, or the conditions of domiciliary life, furnish most 
reliable indices of the state of intellectual and moral advancement in any com- 
munity." 

And he adds, that 

"Though it cannot be assumed that the improvement of man's physical condi- 
tion will alone secure his moral elevation, it is unquestionably true that it con- 
tributes essentially to that important end, and that neither intellectual progress, 
nor moral and social refinement, can be long maintained where the requisite 
conditions for physical health and comfort are not suitably provided." 

If this be true — and who will doubt it ? — the subject of public hygiene rises 
in dignity and importance, in connection with the welfare and progress 
of any people to a level with those of education, and the teachings of the 
pulpit. 

The history of the progress of sanitary improvement given by Dr. Harris, 
of which we have quoted above the opening paragraph, is a clear exposi- 
tion of the several great steps of advancement which have been made in the 
practice of hygiene from the time of Pericles to the present day. Did space 
permit, we would gladly cite further from its pages, especially some of the 
points in reference to the public labours of Dr. Reid, who, from the date of 
his appointment by the Queen in 1843, as one of the first Commissioners 
for Inquiring into the Stale of large Towns, and populous Districts,^^ has 
been a zealous and intelligent labourer in the work of sanitary reform. His 
name, is, however, too closely identified with this and other questions of 
scientific character, to render any further introduction of him necessary to 
the medical public. It suffices to say that his profound scientific acquire- 
ments, and his great practical ability, rendered him essential to that and 



1859.] 



PiOKFORD, Greeniiow, Reid, Hygiene. 



155 



other subsequent great works, and have established his name as one of 
authority in all matters upon which he may speak or write. 

The volume before us, without any special pretensions to anything new, 
is written chiefly for the instruction of the people at large in the theory and 
practice of domiciliary ventilation. In its 34 chapters we believe will be 
found suggestions for the simplest as well as the most elaborate methods of 
supplying buildings fully with fresh, and the removal of vitiated air. To 
those readers who might perchance perceive any difficulty in comprehending 
a dry text, its hundred coloured illustrations will make everything plain. 
The plan of distinguishing the foul air and the fresh, in an apartment, by 
pink and blue tints, is a happy suggestion, and was first employed, if we 
mistake not, by Dr. Reid in some of his Parliamentary Reports. 

Respecting an instance of foul air poisoning, which has recently excited 
a world-wide interest. Dr. Reid's testimony will be regarded as ex cathedra. 

"The noted case of the National Hotel, at Washington, where so many hun- 
dreds suffered very lately, was not unconnected with the condition of the ventila- 
tion. Whether other causes contributed or not, is a question that is not entered 
on here ; recent facts and statements that have been made on this point may leave 
this an open question, till the whole of the evidence on the subject shall be pub- 
lished and compared ; but in the meantime personal observations, at this hotel, at 
the time referred to, gave proof that there was, in one part of the hotel at least, 
a discharge of vitiated air from drains of so intense a character that it produced 
instantaneous vomiting on some occasions, and affected numbers in a less degree 
at the moment, who were nevertheless attacked at a subsequent period." * * * 
"No other cause has yet been proved to have been in operation, and even if it 
were, it would in no way alter the conviction entertained, that the emanations 
from the drains constituted an evil of great magnitude, and capable of producing 
the most disastrous results. Let it be recollected that there are no deleterious 
gases that can arise from the admixture of chemicals that may meet in obstructed 
drains and sewers, that may not find their way into hotels, houses, and other 
buildings, as well as the products of the putrefaction of animal and vegetable 
matters. Sewers may discharge there the products found at the distance of 
miles, particularly if they be trapped so as to exclude the access of air in the 
streets. And who can estimate the emanations that may not proceed from such 
sources, when they arise from chemicals discharged from a manufactory, an apo- 
thecary store, a paint shop, a telegraph office, or the poisoned remains of animals 
that may have accumulated in the sewers ? Further, the very cement or mortar 
may imbibe materials that discharge sulphuretted or arseniuretted hydrogen from 
compound mixtures on fermentation, or from the action of an acid ; and these find 
their way by a retrograde current in the drains and sewers to any building con- 
nected with them where the drains have been injured, and the traps rendered in- 
effective." 

Our own observations at the National Hotel, during the last session of 
the American Medical Association last May, justifies all that we have ever 
heard of the condition of its atmosphere. Some parts of the building have 
never been reached by the sun's rays, and have a graveyard-like dampness, 
while the low ceilings, and the dark, tortuous, and unventilated passages 
and rooms, give forth a musty odour. To our mind it scarcely required 
even the addition of the foul air of an obstructed sewer to produce the sad 
effects attributed to it, much less the drinking of water poisoned by arsen- 
ical rats. 

" The Tenement House, o'er wliich no friendly movement 
Has waved the enchanter's wand of ' modern improvement,' " 

has become one of the Institutions, especially of the city of New York, 
and is thus hygienically painted to the death, by our author, p. 99. 



156 



Reviews. 



[Jan. 



"The staircase lias no supply of air whatever, when the doors below are shut, 
except the small amount that may enter by leakage there ; but sixteen doors on 
the different floors, as well as the basement, may all draw more or less upon the 
passage and stairs when there are many fires kindled, and no windows opened 
for a supply, in consequence of the state of the weather. The result is that one 
or more doors are opened on every floor to derive some benefit from the atmo- 
sphere in the staircase, and the lower floors discharge their vitiated air, which 
ascends and oppresses the occupants of the upper floors. Some of the chimneys 
overpower others, drawing down smoke which pervades the staircase. The occu- 
pants are forced in self-defence to shut their doors and open their windows, till 
the cure becomes worse than the remedy, when they again return to their pre- 
vious position, alternating between these opposite evils so long as they do not 
choose to suffer quietly the inconveniences that result from their unventilated 
dwellings." 

The first remedy for a great portion of these evils, our author suggests, 
is the very sensible one of supplying the entry and stairway with a current 
of fresh air, warmed in winter by a stove in the lower hall, by which simple 
measure the comfort and health of the occupants would be increased more 
than by any other that could be mentioned. 

With plain and practical suggestions like this, adapted to almost every 
kind of inhabited building, this volume abounds. The proper construction 
and arrangement of drains and sewers, and of water-closets, the methods of 
avoiding the effects of noxious gases from manufactories, ''external venti- 
lation,'^^ including the rules which should govern in the choice of a site for 
a dwelling, these and many other cognate matters are well and clearly dis- 
cussed, and cannot fail to impart instruction to all who desire it. 

J. H. G. 



Art. XIII. — Legons sur la Fhysiologie et la Pathologie du Systeme 
Nerveux. Par M. Claude Bernard, Membre de I'Institut, Professeur 
de Medecine au College de France, &c. &c. Paris, 1858. 2 vols. 8vo. 
pp. 560—520. 

These volumes give an account of M. Bernard's last two courses in the 
College of France on the Physiology and Pathology of the Nervous Sys- 
tem ; one delivered in the winter term of 1856-57, the succeeding one in 
the spring term of 185t. The subject is so divided that the first volume 
treats of the general relations of the nerves and the nervous centres, their 
influence upon nutrition, calorification, and the like, and the manner in 
which they are affected by galvanism and other external agents ; while the 
second volume is devoted to the study of individual nerves and the special 
functions of their different branches. 

The author commences, as is almost habitual with him, by defining his 
position in the opening scientific campaign, and by reminding his hearers 
that there are, in the development of the sciences, two distinct depart- 
ments to be cultivated, viz : the discovery of new truths, and the criticism 
or co-ordination of those which have already been acquired. Among the 
cultivators of natural science, the one class strive to extend its limits by the 
introduction of new ideas ; while those belonging to the other are more 
})articularly employed in criticizing the discoveries of the first, and bringing 
them into relation with established opinions." 



1859.] Bernard, Physiology and Pathology of Nervous System. 15T 

Bernard has no hesitation in making the avowal that his own position, 
as conductor of the physiological course at the College of France, placevS 
him in the former category. There is no doubt, beside, that his own pre- 
ference and intellectual tendencies lie in the same direction. It is curious 
to observe, indeed, in the physiological discussions which have arisen in 
France within the last ten or fifteen years, that it is almost always his 
name which appears at the head of new discoveries and innovations ; while 
his statements and doctrines immediately call up a host of critics and in- 
vestigators to assail or corroborate them, and furnish abundant material 
for discussion, examination and counter -experiment, almost without end. 
Striking examples of this are to be seen in the history of the discovery of 
the formation of liver-sugar ; of the influence of the sympathetic nerve on 
calorification ; of the artificial production of diabetes by wounding the 
fourth ventricle ; and of the digestive properties of the pancreatic juice. 

The discovery of the formation of liver-sugar alone, ever since it was first 
announced, in 1848, to the present time, has given rise to almost incessant 
discussions, which even now are hardly to be considered as terminated ; the 
most important part of the whole doctrine, viz., the exclusively internal 
origin of the sugar found in the liver, having been formally assailed no 
longer ago than May, 1857, in a very able and elaborate communication 
addressed to the French Academy by M. Sanson, of Toulouse. During this 
period, the objections raised against Bernard's doctrine have been twice 
made the subject of special investigation by commissions of the French 
Academy, and although in each instance the objectors (including M. San- 
son) failed to make good their statements before the Commissioners of the 
Academy, and though the reports accordingly sustained Bernard's doctrine 
so far as the special points under discussion were concerned, still the ques- 
tion is not yet regarded as altogether settled, nor is there any complete 
unanimity of opinion in respect to its details. So wide is the field of re- 
search which has been opened by one discovery, and so abundant the ma- 
terial for investigation which it has afforded. 

The great advantage resulting from this system of encroachment and 
innovation is that, in whatever way the special questions raised by disco- 
verers may be finally answered, the acquisitions of science cannot fail to be 
largely increased, and its domain enriched by their agitation. Even if it 
should hereafter be shown, for example, that Bernard was mistaken in sup- 
posing his liver-sugar to be actually and exclusively produced in the substance 
of the hepatic tissue, how many new facts, brought out in connection with 
this doctrine and in consequence of its discussion, would remain as permanent 
scientific acquisitions. The constant presence of sugar in the liver during 
health, and its passage thence into the hepatic blood ; the existence of a 
" glycogenic matter," similar or analogous to starch and dextrine, and its 
ready conversion into sugar by animal ferments ; the occasional passage of 
sugar into the circulating fluids throughout the body, and its normal ex- 
istence in the blood and urine during a part of foetal life ; these are all 
facts of the greatest interest for the physiologist, and which certainly would 
not have been discovered except for the attention attracted to the entire 
subject by Bernard's doctrine. Such acquisitions are necessarily evolved 
from the intellectual fermentation, which is excited in the scientific world by 
the contact of new ideas and the stimulus of unexpected discovery. 

Bernard is quite right, therefore, when he maintains that the path of 
experimental inquiry, if followed in the right spirit, must conduct us to more 
advanced posts of knowledge, and result necessarily in enlarging our scien- 
No. LXXIIL— Jan. 1859. 11 



158 



Reviews. 



[Jan. 



tific acquirements. So long as we interrogate nature for the information 
we wish to acquire, and rely solely upon her answers to guide our studies, 
our labour cannot be lost. For, though we may afterwards be compelled 
to modify the conclusions drawn from an experiment, the actual results 
of the experiment itself cannot be modified, but remain good forever. It 
will always be noticed, in fact, even when we seem to have been deceived in 
our investigations, that it is only our interpretation of the experimental 
phenomena which was erroneous. The phenomena themselves, if faithfully 
observed, are never erroneous ; and though our interpretation of them may 
afterwards be altered, the results of the experiment itself must always 
remain the same, and forever bear an undiminished value. 

The principal danger of misinterpreting the results of experiment lies, 
as every one knows, in a too great devotion to preconceived ideas or favour- 
ite theories. This devotion is often an unconscious one on the part of the 
experimenter ; and it is often to be remarked that an author will disclaim 
for himself any preference whatever as to which side of the question under 
investigation may prove the correct one, and will profess the most impar- 
tial desire to arrive at the truth, while his expressions and his mode of 
treating the subject indicate plainly how much he is interested in establish- 
ing a favourite conclusion. The cause of this mental bias is generally to 
be found in the fact that the experimenter fears lest an adverse conclusion 
should destroy the value of previous investigations ; and he is naturally 
unwilling that science should lose the advantage of so much well meant 
labour, and that its acquisitions, once regarded as fully established, should 
afterward turn out to be fruitless. 

Such fears, however, as we have remarked above, are always unfounded. 
The acquisitions of science can never be fruitless, whatever be the result of 
subsequent investigations. Every one who pursues for a series of years 
any department of investigation, finds that his ideas and theories: undergo 
successive changes with the lapse of time. He views the subject in a dif- 
ferent light, and arranges the facts presented to him by nature in a different 
order and relation. But in substituting new theories for the old, he never 
loses anything previously acquired ; on the contrary, the new view which 
he is led to adopt, concerning any set of phenomena, is always more com- 
prehensive and satisfactory than the previous one ; for it includes the new 
facts discovered by experiment, as well as those which had been established 
before. 

It is possible, however, for this truth to be so entirely ignored, and the 
object and purpose of experimentation so thoroughly misconceived, that 
investigation may be resorted to only as a secondary matter, for the pur- 
pose of confirming, or illustrating," as it is called, scientific doctrines. 
This was probably the case with the French savant, mentioned by Bernard 
as a "prominent member" of the Academy of Sciences, though "not par- 
ticularly eminent," he adds, "in experimental physiology." The acade- 
mician had been engaged in preparing a memoir upon an interesting phy- 
siological subject, which he intended to present to his colleagues at their 
next session. In conversing upon the subject with Magendie, he remarked 
that he " should very soon be ready to present his paper ; for the memoir 
itself was already finished, and he had nothing more to do hut to perform 
the experimental 

Bernard gives, in his first chapter, some very judicious directions with 
regard to what he calls the " art of experimentation ;" that is, the manner 
in which experiments should be arranged and their results compared, the 



1859.] Bernard, Physiology and Pathology of Nervous System. 159 

principles upon which they should be contrived, and the care which is re- 
quisite in fixing and regulating their conditions. We shall leave this part 
of the subject, however, and pass immediately to the consideration of a few 
of the most important topics treated of in the body of the work. 

A very prominent place is given, in the early part of the memoir, to the 
study of the recurrent sensibility of the spinal and cranial nerves. As 
the history of this subject is somewhat remarkable in many respects, and as 
the author regards the property of recurrent sensibility as affording very 
important indications in regard to the classification of nerves, it may be 
considered as one of the most interesting topics treated in the present 
volumes. 

It is well known, that of the two roots by which each spinal nerve takes 
its origin from the spinal cord, one is motor and the other sensitive in its 
nature and properties. The anterior root is especially devoted to the func- 
tion of exciting contraction in the parts to which the nerve is distributed, 
and has no relation with the sensibility of these parts ; while the posterior 
root is incapable of exciting motion, by any direct influence, and has, in- 
stead, the power of conveying sensation from the parts in relation with its 
terminal branches. 

If these roots, accordingly, be separately divided, the function of sensa- 
tion or of motion will be abolished, according as the injury has been in- 
flicted on the fibres of the first or the second set. If the anterior root be 
divided, the corresponding part of the body is paralyzed of motion, but 
retains its sensibility; if the section be made of the posterior root alone, 
the sensibility is lost, but the power of motion remains unaffected. 

The properties exhibited by the nervous roots themselves, when directly 
experimented on, correspond with the above functions intrusted to them. 
If the anterior root alone be irritated, by pricking or by the galvanic cur- 
rent, a convulsive movement ensues ; if the posterior root be similarly irri- 
tated, a painful sensation is produced, but no movements follow, excepting 
those of a reflex nature. 

Furthermore, if the anterior root be divided, an irritation applied to its 
detached extremity (or that which is separated from the spinal cord) pro- 
duces instant convulsions, but if applied to its attached extremity (or that 
remaining in connection with the spinal cord), no result follows ; since the 
nerve conveys the motor influence by a direct course to the muscle, and 
must, therefore, in order to produce any effect, be still connected with it by 
continuity of fibre. If the posterior root be divided, however, an irritation 
applied to its detached extremity is without effect; but, applied to its 
attached portion, is instantly followed by a painful sensation. 

These are the properties of the anterior and posterior nervous roots, 
demonstrable by direct experiment, which first attracted the attention of 
investigators, and led them to discover the characteristic functions of the 
two roots, now so well established. Another property, however, was early 
found to reside in the nervous system, which interfered somewhat with the 
completeness of these results, at least so far as regards the posterior roots, 
viz : the reflex action of the spinal cord. For, though irritation of the 
posterior roots has no direct influence on the muscles, yet, in point of fact, 
if these roots be irritated, in the living or recently-killed animal, muscular 
contraction is frequently excited in consequence. This muscular contrac- 
tion, however, following irritation of the posterior roots, is shown to be 
indirect or " reflex" in its nature, by the two following facts. First, if the 
posterior root be previously divided, no muscular contraction is ever pro- 



160 



Reviews. 



[Jan. 



daced by irritation of its detached portion, or that still connected with the 
muscle, but only when the irritation is applied to its attached extremity. 
The motor influence, accordingly, such as it is, is not conveyed in this case 
directly from the nerve to the muscle, but reaches the latter only by first 
passing through the spinal cord. Secondly, if, after performing the above 
experiment, the anterior root be divided, the posterior will then be found 
to have lost all power to excite contraction, which ever part of it be sub- 
jected to irritation. It is only, therefore, through the medium of the ante- 
rior roots that the posterior may sometimes give rise, when irritated, to 
movements of a reflex nature. 

A corresponding class of phenomena, connected with the anterior roots, 
constitutes the property known as the recurrent sensibility of the spinal 
nerves. It has been found that the anterior roots, when irritated in the 
living animal, sometimes give evident indications of sensibility. This sen- 
sibihty is much less acute than that of the posterior roots, but it is still 
asserted, by various observers, to be occasionally so well marked as to leave 
no doubt of its existence. Like the reflex motor action of the posterior 
roots, however, this sensibility is not direct, but indirect, in the manner of 
its production. For, if the anterior root be first divided, it is the detached 
extremity which remains sensitive, the attached portion being then com- 
pletely insensible. Furthermore, if the posterior root be divided, the ante- 
rior is found to have lost the sensibility which it previously manifested. 

The sensibility of the anterior root, therefore, depends upon the existence 
of sensitive fibres, coming from the posterior root, which join the nerve at the 
junction of the two roots, and then retrace their course, along the anterior 
root, toward the spinal cord, in a reversed or ''recurrent," direction. These 
fibres have never been traced by the scalpel, and probably can never be fol- 
lowed out from their commencement to their termination, owing to the 
mechanical difficulties in the way of such a demonstration ; but the above 
phenomena would seem to leave no doubt as to their actual existence. 

The occasional sensibility of the anterior roots of the spinal nerves was 
noticed by Magendie as early as 1822 ; though it does not appear that the 
indirect or recurrent nature of this sensibility was recognized until the year 
1839. At that time, both Magendie and Longet found that the sensibility 
of the anterior roots, when it existed, could be made to disappear by divid- 
ing the posterior roots, and they therefore regarded it as an indirect sen- 
sibility, derived from the fibres of the latter. Longet, indeed, claimed this 
discovery as his own, and maintained that it was he who, after observing 
the phenomenon, communicated it to Magendie. 

Both observers, however, subsequently failed to reproduce the experi- 
ments with their previous results. The anterior roots, when exposed in 
the living animal, always, subsequently to the experiments of 1839, ap- 
peared completely insensible; and this was the case in so many repetitions, 
that the existence of a recurrent sensibility was practically given up by 
nearly all physiologists, and particularly by Longet himself. In his Treatise 
on Physiology, published in 1850,^ Longet repeatedly, and in the most 
explicit manner, declares the anterior roots of the spinal nerves to be 
completely insensible to mechanical irritations of every kind and speaks 
of his earlier experiments, performed in 1839, and which gave a different 
result, as wanting in confirmation, and insufficient in their conclusions. 

Bernard, however, who was also present at the experiments of 1839, 

» Traite de PhTsiologie, par F. A. Longet, Paris. 1850. 



1859.] Bernard, Physiology and Pathology of Nervous System. 161 



could not persuade himself to abandon the facts observed, whatever difficul- 
ties might exist in the way of adopting the conclusions which had been 
derived from them. As he himself expresses it, he " had been a witness of 
these facts ; he had seen them and touched them ; and, notwithstanding 
that, in the latter experiments of Magendie, the recurrent sensibility of the 
anterior roots was no longer to be found, he could not on that account 
ignore the existence of what he had seen before." 

The manner in which Bernard was again led to discover the recurrent 
sensibility, illustrates very forcibly the care which it is necessary to take in 
regulating the conditions of a physiological experiment, if we wish to obtain 
from it uniform results. 

"I recollected," he says, ''that in 1839, at which time I attended the course of 
Magendie, that all the preparations for the experiment were made in the morn- 
ings, and that it was only afterward, during the demonstrations in the amphi- 
theatre, and when the animal had been allowed to repose, that the experiment 
was tried, and the anterior roots gave signs of sensibility. In the subsequent 
trials, however, the anterior roots were subjected to irritation immediately after 
having been exposed to view,*and they were then found to be insensible. I had 
even supposed this promptitude in conducting the experiment to be a condition 
favourable to success. But after further reflection upon the condition of the ani- 
mals in which I had before seen the recurrent sensibility to exist, the opposite 
condition appeared to be the reason of the phenomena which were observed ; for, 
in those instances, the animal had been left for several hours in repose after the 
preparations for the experiment were made, and this, by allowing him to recover 
from the fatigue of the operation, must have brought back the nervous pheno- 
mena, more or less completely, to their normal condition." 

From 1841 to 1846, accordingly, all attempts to demonstrate anew the 
existeqce of recurrent sensibility were without success. But afterward, by 
modifying and varying the conditions of the experiment, Bernard obtained 
a different result. He found, as above intimated, that a certain period of 
repose was necessary to enable the animal to recover from the immediate 
effects of the severe operation of opening the spinal canal, the loss of 
blood, the cooling of the spinal cord from contact with the atmosphere, &c. 
&c. He found, in certain instances, that where the operation had been 
long and difficult, and had been accompanied by a considerable hemorrhage, 
not only were the anterior spinal roots immediately afterward insensible to 
irritation, but the facial nerve, which every one knows to possess a certain 
degree of sensibility, was also insensible at the same time, owing to the 
partially exhausted and inexcitable condition of the entire nervous system. 
It was also found necessary to make only a small opening in the spinal 
canal, just sufficient to expose the roots of the nerves, and not large enough 
to uncover the entire thickness of the cord itself. All these conditions, 
however, being fulfilled, a vigorous and well-fed animal being selected for 
the experiment, a small opening being made in the spinal canal, by a rapid 
operation, without much hemorrhage, and the animal then allowed to re- 
main at rest for an hour or two, the anterior roots nearly always showed 
themselves sensitive to mechanical irritation. In this way, Bernard has 
again demonstrated, since 1846, the recurrent sensibility of the anterior 
roots, which, for a certain interval, had been a lost fact to science. 

It is worthy of remark, however, that Longet still adheres to his belief 
in the non-existence of what he calls the " pretended recurrent sensibility" 
of the anterior spinal roots. In the second volume of his Treatise on Phy- 
siology, above alluded to (Part II. p. 274), he speaks of this subject as 
follows : — 



162 



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[Jan. 



"If the recurrent sensibility of the anterior spinal roots should be regarded 
as real, I might still insist, as in 1839, upon my right to its discovery; since I 
was the first who, at that period, directed the attention of physiologists to the 
extinction of this sensibility which follows division of the corresponding poste- 
rior root. But since then, in many hundreds of experiments, whether I removed 
one, two, or several of the vertebral arches, or whether J allowed my animals to 
repose or not, after the preliminary operation, I never observed, in any instance, 
the pretended recurrent sensibility of the anterior roots ; and I have, therefore, 
been led to abandon my old opinion, which Magendie has recently (1847) again 
brought forward as the expression of the truth. I nevertheless continue to place 
full confidence in the later experiments by which I demonstrated the constant 
and absolute insensibility of the anterior spinal roots and the anterior columns 
of the spinal cord." 

Longet even intimates (page 10 of same volume) that the experimenters 
who differ with him on this point may have been misled by a faulty method 
of operating. 

"I said," he remarks, "that I had constantly found the anterior roots, when in 
a condition of integrity, to be completely insensible to mechanical irritations of 
every kind; and that, on the other hand, the posterior roots had always shown 
themselves extremely sensitive. But I have sometimes found in the dog, as well 
as in the human subject, three distinct branches of origin for one lumbar or 
sacral nerve, running parallel with each other in the spinal canal ; two of them 
belonging to the posterior root, and the third being the anterior root. This seems 
an important fact to remember, since, when meaning to seize with the forceps the 
anterior root, one might lay hold of that division of the posterior root which lies 
in front of the other, in which case the signs of a very acute sensibility would 
not fail to be manifested. It is essential, therefore, to guard against this source 
of error, which has not heretofore been noticed, and which is undoubtedly the 
reason why the anterior roots have been thought to exhibit sensibility." 

Bernard, nevertheless, actually exhibited with success the presence of re- 
current sensibility in the anterior spinal root, if we are to judge from the 
context (Vol. I., Lecture 4th, p. 73); and he gives also the following 
rules, which should be observed in order to insure success in the experi- 
ment. 

I. The animals selected for operation should be young, vigorous, and 
well fed. 

II. When the animal has not been exhausted or enfeebled by the opera- 
tion, recurrent sensibility may be exhibited by the anterior roots immedi- 
ately afterward. 

III. But if the animal have become exhausted during the operation, 
which is most frequently the case, the anterior roots, examined immediately 
afterward, may appear completely insensible. Then, if the wound be closed 
by sutures, and the spinal cord covered with integument, by waiting a 
certain time for the animal to recover his strength, the recurrent sensibility 
becomes re-established. 

IV. The preferable mode of operating consists in opening only one late- 
ral half of the spinal column, in such a manner as to expose one or two 
nervous roots as far as the ganglion. . In this way, the spinal cord is less 
liable to be affected by cooling; and 

Y. The anterior roots selected for experiment should be those of the 
largest size. 

Such is the history of opinion on this singular property of the anterior 
spinal roots. In the opinion of Bernard, it is of great importance, as com- 
pleting the physiological union between the two roots, motor and sensitive, 
of the spinal nerves. These roots have opposite properties and functions, 



1859.] Bernard, Physiology and Pathology of Nervous System. 163 

but they are still intimately associated, and are necessary to each other's 
perfect functional activity. The sensitive parts cannot give us complete in^ 
formation with regard to any foreign body, unless they are properly applied 
and adapted to it by the aid of the muscles; and the muscles cannot con- 
tract with certainty and efficiency, unless sensibility is also present, to enable 
us to appreciate the direction and force of their movements. As the pos- 
terior roots, furthermore, are connected with the anterior by the property 
of reflex action, so the anterior are connected with the posterior by their 
recurrent sensibility. 

Bernard even assumes — somewhat arbitrarily, as we think — that the exist- 
ence and source of recurrent sensibility in a motor nerve indicate the sensitive 
roots with which that nerve is associated to form a complete nervous pair; 
that is, if there be any doubt to which pair of nerves a motor branch belongs, 
he ascertains from which of the posterior roots it derives its recurrent sensi- 
bility, and then regards it as anatomically a branch of that nerve alone. This 
is undoubtedly allowable in the case of the spinal nerves, where the anterior 
and posterior roots are all arranged in regular pairs ; but its application as 
a constant rule to the cranial nerves, where there are great variations in the 
anatomical arrangement, seems of doubtful propriety. 

The author treats at considerable length (Chapters YIII., IX., and X.) 
of the effects produced on the nerves by the stimulus of galvano-electricity ; 
the special influence of the direct and inverse currents, and 6f the continuous 
and interrupted currents; and of the differences in reaction, under the elec- 
trical stimulus, of motor, sensitive, and mixed nervous filaments. All these 
details, however, though useful for the experimenter who devotes himself to 
that particular field, possess but little general interest, and really throw little 
or no light on the true physiological properties of the nervous fibre. They 
provide us with the means of more accurate investigation, but are not in 
themselves particularly valuable or interesting, as a separate class of phe- 
nomena. 

In the chapter devoted to the properties and function of the spinal cord, 
Bernard sustains the doctrines promulgated of late years by Brown-Sequard, 
as to the transmission of sensitive impressions in a crossed direction, the pro- 
duction of hypersesthesia by section of a lateral half of the cord, and the part 
taken by the gray matter as a conductor of sensibility. The anterior as well 
as the posterior columns are sensitive to mechanical irritation, provided the 
same precautions be observed which are necessary in demonstrating the re- 
current sensibility of the anterior roots. The sensibility of the anterior 
columns is, in fact, a recurrent sensibility, and can be made to disappear, 
over a limited space, by dividing either the anterior root originating from 
the cord at that part, or the corresponding posterior root. Section of a 
lateral half of the cord is followed by an exaggeration of sensibility in the 
corresponding side of the body below the point of section, and a diminution 
of sensibility on the opposite side. Finally, after section of the right late- 
ral half of the spinal cord, if the anterior, lateral, and posterior columns of 
white substance on the left side be also divided, leaving only the gray sub- 
stance entire, sensibility still persists in the right side of the body below the 
point of section. 

Sensitive impressions are therefore transmitted, in the spinal cord, through 
the medium of the gray matter, and in a crossed direction; those coming 
from the right side of the body passing by the left half of the cord, and those 
coming from the left side of the body by the right half of the cord. 

The exaggeration of sensibility after division of a lateral half of the cord. 



164 



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though a phenomenon very difficult of explanation, seems at the present day 
to be perfectly well established. It undoubtedly accounts for another sin- 
gular fact, frequently noticed by experimenters, viz., that the phenomena of 
reflex action of the spinal cord are usually much more energetic after the 
decapitation of the animal than any movements of a similar nature which 
we know to take place during life. This increased activity is probably due 
to an exaggeration of sensibility consequent upon section of the cerebro- 
spinal axis ; , only in this case the sensibility is an unconscious one, and pro- 
duces no other movements than those of a reflex character. 

In the second volume the author takes up in succession the different cra- 
nial nerves, and examines their properties, their functions, the effect of their 
division in various parts of their course, the nature and destination of their 
various branches, &c. &c. The peculiar alteration and destruction of the 
eyeball, after section of the fifth pair within the cranium, is dwelt upon at 
length, and various instances are related of an alteration of the sense of taste, 
dependent on paralysis of the facial nerve in the human subject. Bernard 
has also demonstrated a similar alteration of the taste in the dog, after divi- 
sion of the facial nerve within the skull. The effects of division of the 
pneumogastric, upon the pharynx, larynx, oesophagus, lungs, heart, stomach, 
&c., are also described in detail. 

The chapter (Jevoted to the discussion of the spinal accessory is princi- 
pally a reproduction of the elaborate monograph upon this nerve published 
by the author in 1851. Some years before, Bischoff had published a memoir, 
in which he maintained the opinion that the spinal accessory was to be re- 
garded as bearing the same relation to the pneumogastric, that the anterior 
or motor root of a spinal nerve bears to its posterior or sensitive root ; in 
other words, that the spinal accessory and pneumogastric are associated 
with each other as motor and sensitive roots, forming by their inosculation 
a complete physiological pair, like each one of the spinal nerves. 

This was soon after the discovery of the distinctive properties of the an- 
terior and posterior spinal roots had been followed by the brilliant general- 
izations of the transcendental anatomists, by which the skull was shown to 
be in reality a continuation of the spinal column, and to be composed of a 
series of cranial vertebrae, entirely analogous in their connection and rela- 
tions with the vertebrae of the spinal column. 

It was easy to see, also, that the nervous centres, and the nerves originating 
from them, presented, to a great extent, similar analogies in their different 
parts ; and the cranial nerves were therefore examined, to ascertain how far 
they could be classified according to the principle which regulated the ar- 
rangement of the rest of the cerebro-spinal system. The three nerves of spe- 
cial sense — the olfactory, optic, and auditory — evidently presented no analogy 
with the spinal nerves proper, either in their functions or their anatomical 
arrangement. With regard to the others, however, a very striking analogy 
could easily be seen to exist. The Fifth pair, more particularly — having a 
small and a large root, shown to be respectively motor and sensitive in their 
nature, the large root provided with a ganglion (Casserian), and the two 
afterwards mingling their fibres to form a mixed nerve (inferior maxillary 
branch) — was evidently to be regarded as constructed upon the same plan 
as a spinal nerve, presenting only those modifications of detail necessarily 
connected with the peculiarities in the form of the skull. 

It required only a further development of the same ideas, to classify most 
of the other motor and sensitive cranial nerves — such as the oculo-motorias, 
facial, glosso-pharyngeal, and sublingual — in a similar manner; and it was 



1859.] Bernard, Physiology and Pathology of Nervous System. 165 



the object of Bischoff to complete the above systematic arrangement by 
including the spinal accessory with the pneumogastric, as forming together 
the last pair of the true cranial nerves. He sustained this view by declaring 
the pneumogastric to be exclusively sensitive at its origin, and the spinal 
accessory to he purely motor. The ganglion of the pneumogastric, situated 
in the jugular fossa, he compared with the ganglia of the posterior roots of 
the spinal nerves; while the internal branch of the spinal accessory, joining 
the pneumogastric below its ganglion, completed, according to his view, the 
anatomical union of the two roots, making the trunk of the pneumogastric 
a mixed nerve, containing both motor and sensitive fibres, like the spinal 
nerves outside the vertebral canal. 

The view thus brought forward by Bischoff was received with great favour 
by anatomists and physiologists. The analogies upon which it was based 
were, indeed, in many respects so striking, that they could be regarded in no 
other light than as the expression of actual anatomical relations existing be- 
tween the two nerves. By following out this idea all the cranial nerves, with 
the exception of the three nerves of special sense, may be arranged in pairs, 
like those of the spinal nerves, according to the distribution of their motor 
and sensitive filaments. All the branches of the fifth pair emanating from 
the Casserian ganglion supply the region of the face with general sensibility ; 
while the smaller root of the same nerve, together with the facial and the 
motor nerves of the eyeball, supply the same parts with the power of mo- 
tion. The sublingual and the glosso-pharyngeal supply respectively the 
muscles and mucous membrane of the tongue; while the pneumogastric and 
spinal accessory perform the same office for the various parts to which these 
nerves are distributed, viz., the muscular and mucous coats of the respira- 
tory passages and upper part of the alimentary canal. The fact that the 
oculo-motorius, patheticus, external motor, facial and masticatory nerves, 
pass out from the skull in separate - bundles, cannot of itself prevent our 
regarding them as physiologically the same nerve ; since the physiological 
identity of any motor branches does not depend so much upon their follow- 
ing the same course, as upon their being finally distributed to the same re- 
gions. Even the anterior roots of the spinal nerves originate from the 
spinal cord by many distinct filaments, and are only collected into a single 
trunk at a certain distance from their point of origin. 

The cranial nerves, then, which are similar in their nature to the spinal 
nerves, may be arranged, if we adopt this view, in three distinct pairs, each 
consisting of a motor and a sensitive element, as follows : — 



1st Pair 

2d Pair 
3d Pair 



Motor Portion. 
Oculo-motorius. 
Patheticus. 
iMotor Externus. 
Facial. 
Masticatory. 
Sublingual. 

I Spinal Accessory. 



Sensitive Portion. 

Sensitive branches 
of "5th Pair." 

Glosso-pharjngeal. 
Pneumogastric. 



Distributed to 



Face. 



Tongue. 

Pharynx, larynx, trachea, 
oesophagus, lungs, and 
stomach. 



The doctrine which regards the spinal accessory as the motor root of the 
pneumogastric nerve receives a striking confirmation from the fact that if 
the spinal accessory be divided at its origin, the laryngeal muscles, supplied 
by a branch of the pneumogastric, are thereby paralyzed to such an extent 
that the animal loses the power of producing a vocal sound. This singu- 
lar fact, viz., the loss of voice after section of the two spinal accessories 



166 



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before their junction with the pneumogastrics, was verified by Bischoff in one 
successful operation, after several failures ; and shows conclusively that some, 
at least, of the motor filaments of the pneumogastric are derived exclusively 
from the spinal accessory. 

Bernard confirms entirely the above fact from the result of his own ex- 
periments. Indeed, his success in performing the operation without inflict- 
ing serious injury upon the animal, has been so much greater than Bischoff 's, 
that he seems to have at least an equal claim with the German experimenter, 
to the establishment of the discovery. The earlier operations consisted in 
cutting down upon the occipito-atlantoidean membrane, dividing it by a 
transverse incision, and then cutting off the spinal accessory nerves upon 
each side through this opening. The external wound, however, in this 
operation was very large and deep, and in order to reach the superior fibres 
of the spinal accessory it was usually necessary to cut away a part of the 
occipital bone; a proceeding almost necessarily followed by troublesome and 
exhausting hemorrhage from the occipital sinuses. The introduction of air 
into the veins, owing to the opening of the osseous sinuses, was also found 
to be a frequent cause of death, during the operation, and consequent failure 
of the experiment. 

Bernard, however, contrived an extremely ingenious operation, by which 
all these difficulties were remedied. It consists in cutting down upon the 
spinal accessory just as it emerges from the jugular foramen, seizing at the 
same time both the external and internal branches between the blades of a 
forceps, and by a steady, continuous traction tearing away the nerve from its 
roots. The only difficulty in performing this operation consists in the depth 
of the wound, at the bottom of which the nerve is to be seized and extracted ; 
owing to which the operator may sometimes fail to grasp the internal or 
anastomotic branch of the spinal accessory, and lay hold only of the exter- 
nal division of the nerve, which is distributed to the muscles of the neck. 
When both branches, however, are grasped by the forceps and the traction 
properly made, the roots of the nerve give way at their origins, even down 
to the lower part of the cervical region of the cord, and the whole nerve 
comes away as a slender white filament, an inch and a half to two inches 
long, terminating in a fine, threadlike extremity. The operation is more 
readily performed on cats than on dogs, owing to the greater density of the 
fibrous tissues in the latter, in consequence of which the nerve is apt to be 
broken, in the effort to bring it away at its roots. 

This operation, when successful, leaves the animal with a simple and not 
very extensive wound of the integument and muscles, which involves no 
injury to any important organ, and which readily heals, leaving the animal 
in a favourable condition for exhibiting the effects of division of the nerve, 
uncomplicated by any other affection or mutilation. 

We have already mentioned that the principal effect of this operation is 
a complete and permanent loss of voice, and that it shows conclusively that 
the internal or anastomotic branch of the spinal accessory supplies to the 
pneumogastric, and through it to the larynx, all the motor fibres concerned 
in the production of vocal sounds. 

Bernard, however, is nevertheless unwilling to regard the spinal acces- 
sory as representing the motor root of a mixed nerve, of which the sensitive 
root would be the fibres of origin of the pneumogastric. His objections to 
this view are both anatomical and physiological in their nature. The pecu- 
liarities of the anterior roots of the spinal nerves, with which Bischoff 
would compare the spinal accessory, are the following ; — 



1859.] Bernard, Physiology and Pathology of Nervous System. 167 



1. They origmate from the antero-lateral columns of the spinal cord. 

2. They join the posterior roots beyond the situation of the ganglion 
belonging to the latter. 

3. They form, together with the posterior roots, a mixed nerve, to every 
part of which they supply motor fibres. 

The objections of Bernard to the view advanced by Bischofif begin with 
the very origin of the nervous filaments. 

"In the first place," he says, "the mode of origin of the spinal accessory is 
not the same with that of an anterior root. The source of this nerve extends 
over a very considerable portion of the cord, while each anterior spinal root 
originates from a very limited point. Furthermore, instead of commencing, hke 
the true anterior roots, from the line of separation between the anterior and 
lateral columns of the cord, the fibres of origin of the spinal accessory emerge 
from a part of the cord much further back, and very near, as we shall see, to the 
posterior column." 

" Towards the upper part of the neck, the roots of the spinal accessory are 
comparatively long, and the trunk of the nerve, running along the side of the 
spinal cord, rests upon the superior surface of the ligamentum denticulatum. 
As we go further down the neck, however, the roots of the nerve become shorter 
and shorter, and its trunk is consequently brought nearer the posterior columns, 
so that in the lower part of the neck it is placed very far back and in the imme- 
diate vicinity of the posterior spinal roots." 

The mode of union of the spinal accessory with the pneumogastric is also 
regarded as differing, in an important respect, from that of the anterior 
and posterior spinal roots. 

" A weighty objection is to be made against the view taken of the anastomosis 
of the spinal accessory, in its relations with the ganglion of the pneumogastric. 
It is well known that each anterior spinal root unites with the posterior root a 
little beyond the intervertebral ganglion belonging to the latter. Most authors, 
considering the jugular ganglion of the pneumogastric, or that which is seated 
upon the nerve at the point where it enters the posterior foramen lacerum, as 
the analogue of the intervertebral ganglion of a posterior spinal root, have thought 
to sustain their doctrine by relying upon the fact that the spinal accessory unites 
with the pneumogastric below this ganglion. But in the first place it ought to 
be shown this ganglion of the pneumogastric is really analogous to the interver- 
tebral ganglion of a posterior spinal root. Now it is easy to demonstrate that 
the only ganglion which could be compared with those of the posterior roots is 
that situated on the trunk of the pneumogastric, below its anastomosis with the 
spinal accessory. This ganglion in certain animals, as the cat and the rabbit, is 
very visible and distinctly marked, while in the human subject it is represented by 
a kind of diffused gangliform swelling, to which is given the name of the -plexus 
gangliformis, and which was very correctly described by Scarpa. The anasto- 
mosis of the spinal accessory differs accordingly from that of the anterior spinal 
roots, since it really joins the pneumogastric above the ganglion which is analo- 
gous to that of a posterior root." 

M. Bernard does not intimate what are the anatomical grounds upon 
which he considers it "easy to demonstrate" that it is the cervical and 
not the jugular ganglion of the pneumogastric which represents an inter- 
vertebral ganglion of the posterior roots. We should have been glad if he 
had stated the reasons for this opinion more fully ; for we cannot say that, 
in the absence of further explanation, they are very clear. On the contrary, 
it seems to us that the jugular ganglion of the pneumogastric, occupying 
the jugular fossa, is much more properly compared with the intervertebral 
ganglia, situated in the intervertebral foramina, than the cervical ganglion 
which is altogether outside the skull, particularly as the pneumogastric 
gives off one of its branches (pharyngeal) above this ganglion, though be- 



168 



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[Jan. 



low the other. The jugular foramen is certainly altogether analogous, in 
its anatomical relations, with the intervertebral foramina ; and it would 
seem natural, therefore, to regard the ganglia which it contains as analo- 
gous to those situated in the latter. 

There are other reasons, however, which lead Bernard to decide against 
the view entertained by Bischoff, as to the analogies of the spinal accessory. 
He lays a great deal of stress, for example, on the existence and source of 
the recurrent sensibility of a motor nerve, in determining its physiological 
relation with sensitive roots. 

"We must now examine," he says, "by this new criterion the question of the 
association of the pneumogastric and the spinal accessory. We wish to know, 
in a word, whether the spinal accessory be the anterior root of the pneumogastric. 
For that purpose, we must ascertain whether the recurrent sensibility of the 
spinal accessory be derived from the pneumogastric, in the same manner as the 
recurrent sensibility of an anterior spinal root comes from the corresponding 
posterior root. If the pneumogastric furnish sensibility to the spinal accessory, 
we shall in that case be justified in saying that it plays the part, toward this 
nerve, of a posterior root. If the contrary should prove true, then the question 
must be decided differently ; since the essential property which characterizes the 
association of the two roots of a pair of spinal nerves would not be found to exist 
between the pneumogastric and the spinal accessory," 

" Now I have convinced myself that the recurrent sensibility of the spinal 
accessory, a property which I have found very distinct and well marked in this 
nerve, in the dog, the rabbit, and the goat, is not at all diminished by section of 
the pneumogastric ; proof positive that it is not this nerve which furnishes the 
former with recurrent sensibility, I shall show subsequently that this recurrent 
sensibility of the spinal accessory is derived from the posterior root of the four 
upper cervical nerves ; so that, according to this view, the spinal accessory 
should be regarded as a motor root superadded to the anterior roots of the four 
upper cervical nerves, since its recurrent sensibility is derived from the same 
source with theirs." 

Finally, the physiological properties of the spinal accessory, as a motor 
nerve, are not such, in the opinion of the author, as to make it, properly 
speaking, the anterior root of the pneumogastric. It is true that it fur- 
nishes some motor fibres to the latter nerve, but not by any means all that 
it contains, nor even the most important of them. In the inferior laryn- 
geal nerve, for example, a branch of the pneumogastric, the only motor 
filaments paralyzed by section of the spinal accessory are those concerned 
in the production of vocal sounds. The respiratory movements of the 
larynx go on perfectly well afterward, for the motor powers of the pneu- 
mogastric concerned in this function are derived from other sources. 

The function of the spinal accessory, indeed, as connected with respira- 
tion, is a very curious one, if M. Bernard's views be correct ; and we see 
no reason why they should not be admitted, in this particular, to be in 
accordance with all the known facts. 

Sir Charles Bell considered the spinal accessory as an assistant in the 
movements of respiration, as complementary to the intercostals and dia- 
phragm, and as calling the stern o-mastoid and trapezius into play when unu- 
sual force is required to expand the chest, as in laboured respiration. It 
seems, however, according to Bernard, that though this nerve be really 
connected with the respiratory function, the relation between the two is 
somewhat dilferent from that stated above. Its influence is, indeed, an- 
tagonistic rather than favourable to the movements of inspiration. In the 
larynx, for example, we know that the spinal accessory presides over the 
formation of vocal sounds. Now these sounds cannot be made during 



1859.] Bernard, Physiology and Pathology of Nervous System. 169 

inspiration. They require the close approximation of the vocal chords, 
and a prolonged, sustained, and unusually forcible expiration, in order to 
produce the vibration in the larynx necessary to their formation. While 
the voice is in operation, therefore, breathing is temporarily suspended ; and 
it is suspended by the action of the same nerve which produces, through its 
motor influence, the vocal sounds. 

Such is the function of the internal or anastomotic branch of the spinal 
accessory. 

Again, respiration is suspended in all those prolonged and violent mus- 
cular efforts which require the spine and thorax to be firmly fixed, as a point 
of support to the limbs and muscles of the trunk. A free inspiration can- 
not be made, as we may very easily convince ourselves, unless these parts 
be in a certain state of relaxation ; and the instant any strong muscular 
effort is to be made, respiration is instinctively suspended. Now the stern o- 
mastoid and trapezius muscles, instead of acting, when under the direction 
of the spinal accessory, to increase the respiratory effort, are stimulated on 
the contrary to fix the chest and shoulder in an immovable position, and 
put a stop to respiration while the unusual muscular exertion continues. 
This is the function, according to M. Bernard, of the external or muscular 
branch of this nerve. 

With regard to the analogical relations of the two nerves under discus- 
sion, it is a matter of less importance to classify them in a regular order, 
either together or separately, than that we should know all their peculiari- 
ties, and in what particulars they resemble or differ from the other nerves 
originating from the cerebro-spinal axis. All the cranial nerves present 
certain modifications in their course and distribution, by which they vary 
more or less from the regular type of the spinal nerves. These modifica- 
tions they present in common with the nervous centres of this part and the 
cranial bones which inclose them. If it is not necessary, therefore, to insist 
upon absolute coincidence in every anatomical detail, in order to justify a 
general analogy between these nerves and the regular pairs of anterior and 
posterior spinal roots. 

Still, the peculiarities of origin and function belonging to the spinal 
accessory are so marked as to separate that nerve, more widely than most 
others, from the regular type of anterior spinal roots. It is doubtful, in- 
deed, whether that portion which originates from the spinal cord in the 
cervical region should not be separated physiologically, as it is separated 
anatomically (by the posterior cerebellar artery), from that portion origi- 
nating from the medulla oblongata ; particularly as experiment shows that 
the latter portion alone furnishes the internal or anastomotic branch, while 
the cervical portion is probably destined altogether for the external or 
muscular branch. The function of the spinal accessory, at least so far as 
it is distributed to the larynx, is undoubtedly, also, one of a peculiar and 
special nature. Its action in exciting the movements of the laryngeal mus- 
cles, and the modulation of the voice, is beyond question a peculiar one, 
and quite different from the ordinary motor action of a spinal nerve. 

One of the strongest reasons, however, against considering the spinal 
accessory and pneumogastric as representing the motor and sensitive roots 
of a spinal pair, lies in the extremely peculiar nature of the sensibility be- 
longing to the pneumogastric itself. It is not a nerve endowed with any 
acute general sensibility. It may often be divided, as Bernard testifies, in 
the living animal, without eliciting any sign of pain ; while in the mixed 
and sensitive spinal nerves, and even more especially in the fifth pair of 



Reviews. 



[Jan. 



cranial nerves, a mere touch will produce the most acute suffering. It is 
a special sensibility, connected with the functions of the lungs and the sto- 
mach, which is confided to the pneumogastric, and not the ordinary sensi- 
bility characteristic of the spinal nerves. We beheve, therefore, that the 
real analogies of the case would be best satisfied by withdrawing both the 
pneumogastric and the spinal accessory from the general category of the 
cranial and spinal nerves, as we have already withdrawn the nerves of 
special sense, and by considering them as a motor and sensitive pair, differ- 
ing from the others in the essential nature of the function intrusted to 
them, as well as in certain details of anatomical distribution. 

If we still wish to classify the remaining cranial nerves in a regular 
series, we can do so by slightly modifying the original plan, and by making, 
at the same time, four pairs of cranial nerves instead of three ; an arrange- 
ment more in harmony with the requirements of transcendental anatomy, as 
they are at present generally understood. By this plan, the pneumogastric 
and spinal accessory are left out of the list altogether, as being nerves of a 
special nature and destination. The three sensitive branches of the trige- 
minus are regarded as distinct nerves, distributed to separate regions of the 
face; and the glosso-pharyngeal constitutes the sensitive portion of the 
fourth and last pair. The list of cranial nerves would then be arranged 
as follows : — 

Motor portion. Sensitive portion. Distributed to 

1 P . J Oculo-motorius. Ophthalmic branch of " 5th ) , . , . 

1st Pair < Patheticus. Dair " t Upper facial region. 

( Motor externus. P • J 

2d Pair Facial. " Sth^a^! " ^'^""'^ } ^^^^^^ ^^''^^ ^^S^^^' 

o T, Tk/r X- i Inferior maxillary branch It * • i 

3d Pair Masticatory. "5th pair " Lower facial region. 

4th Pair Sublingual. Glosso-pharyngeal. Tongue and fauces. 

In the chapter devoted to the study of the pneumogastric, the author 
insists upon the peculiar character of the sensibility of this nerve, and upon 
its want of general sensibility. This insensibility of the nerve to ordinary 
painful sensations is sometimes complete ; and when the pneumogastric 
shows signs of sensibility they are nearly always of an obtuse character.'* 
The probable cause of the difference in this respect, shown by the nerve in 
different instances, is thus given by the author : — 

"I have often," he says, "experimented upon dogs, in order to ascertain the 
conditions regulating the sensibility or insensibility evinced by the pneumo- 
gastric. i have not yet succeeded in arriving at a perfectly satisfactory expla- 
nation of all the phenomena observed; yet it has seemed to me, judging from 
the greater number of instances, that the pneumogastric is insensible in dogs 
while fasting, but sensitive during digestion. At tlie same time, J am far from 
offering this statement as the expression of an established fact. At all events, 
there is some modification of the sensibility in these cases — dependent, no doubt, 
on the special nature of the nerve — which demonstrates plainly that, in this re- 
spect, the comparison which has been drawn between the pneumogastric and a 
posterior spinal root, is an incorrect one." 

In the remaining portions of the work, devoted to the history of the 
pneumogastric and the great sympathetic, there are many interesting details 
of experiments, though we do not find here anything particularly novel in 
the statements presented. The effects of dividing the different branches of 
the pneumogastric, as exerted upon the larynx, the lungs, the heart, and 



1859.] Bernard, Physiology and Pathology of Nervous System. 171 



the stomach, are fully discussed, and the different modes of death in these 
experiments explained, so far as they have yet been successfully investi- 
gated. 

The author describes, also, the increase of animal temperature produced in 
the head and face after dividing the sympathetic nerve in the neck ; and main- 
tains, in opposition to Brown-Sequard and some others, that this effect is 
not due to a mere accumulation of blood by paralysis and distension of the 
vessels. He regards the increase of temperature, in a word, as an active 
and not a passive phenomenon ; similar to the engorgement which takes 
place in a glandular organ, when, from a quiescent state, it passes suddenly 
into a condition of active secretion. This opinion has been maintained 
before, by relying upon the fact that an artificial stasis of the blood induces 
rather a diminution than an increase of temperature. If the veins coming 
from the ear of a rabbit, for example, be tied so as to arrest the return of 
blood, and confine it in the vessels of the part, the organ grows cooler as 
stasis becomes fully established. It may be very properly objected to this 
experiment, however, that though the quantity of blood contained in the 
vessels of the parts is thereby increased, the quantity actually floioing 
through them is diminished, and we cannot expect the phenomena of nutri- 
tion and calorification to be intensified when the nutritive fluid is prevented 
from arriving at the organ by the same means which prevents its depar- 
ture. 

The following experiment related by Bernard, however, is not, as he thinks, 
open to any such objection as the above, and leads to the same conclusion 
in a more satisfactory manner. He first ties the veins coming from both 
ears of a rabbit ; and after the stasis of the blood, and consequent cooling 
of the parts on both sides, have become fully established, he divides the 
great sympathetic, on one side, in the middle of the neck. The immediate 
effect of this operation is a rise in temperature on the corresponding side, 
and, as both sides are in the same condition as to accumulation of blood, 
the rise of temperature in this case is thought to be necessarily due to some 
other cause, operating as an active stimulus to the tissues or the capillary 
bloodvessels. 

It must be acknowledged that the nature and functions of the sympathetic 
are still shrouded in the greatest obscurity ; and the difficulty of isolating 
it from surrounding parts, without inflicting extensive mutilations upon the 
animal, will undoubtedly be, for a long time, a serious obstacle in the way 
of experiments on this part of the nervous system. Its numerous ganglia, 
scattered everywhere at short intervals throughout its course, make it diffi- 
cult, also, to determine the true direction of any particular set of its ner- 
vous filaments ; while it reacts so sluggishly to all artificial stimulus, that 
direct experiment has so far produced very unsatisfactory results. Bernard, 
however, gives a very complete account of all that has been ascertained in 
regard to it up to the present time. He finishes the subject with some 
considerations as to the effect of dividing the sympathetic, and of wounding 
certain parts of the medulla oblongata and spinal cord, in stimulating and 
modifying certain of the secretions. J. C. D. 



172 



Reviews. 



[Jan. 



Art. XIY. — The Diagnosis of Surgical Cancer. By John Zachariah 
Laurence, P. R. C. S., M. B. Lond. Second edition. London : John 
Churchill, 1858. 8vo. pp. 126. 

No subjects command greater interest at the present time than cancer 
and tubercle. Upon none is professional opinion more divided. The most 
opposite views are entertained as to the essential nature of these new 
formations, as to their heterologous or homologous character, the causes 
determining their occurrence, the legitimate means of diagnosis, and above 
all, as to the possibility of successful treatment. The subject of the little 
work before us, therefore, commands for it at once ready attention. It 
does not profess to be a systematic treatise upon cancer, but is limited to 
the question of diagnosis, and especially as applied to those cases in which 
the presence of an external tumour brings the disease under the charge of 
the surgeon. 

The term cancer is employed by the author in its broadest sense, to sig- 
nify the whole class of carcinomatous diseases. Applying this term to the 
group, or, as he designates it, ''the genus," he discriminates the following 
"species:" 1. Scirrhus. 2. Encephaloid. 3. Melanotic cancer. 4. Vil- 
lous cancer. 5. Osteoid cancer. 6. Colloid cancer. After a number of 
illustrative cases, referring especially to melanotic, villous, and osteoid 
cancer, the second chapter proceeds to present the data on which a diag- 
nosis is to be based, considering the first two species as typical. 

The data which will justify an accurate diagnosis and a wise prognosis, 
are to be sought : 1. In the presence or absence of the so-called predispos- 
ing and exciting causes; and 2, in the symjptoms o/ ^Ae case; which are 
classed under the following heads : A. Special previous history. B. Con- 
dition of patient when first brought under observation. C. Anatomy of 
the tumour. 

With regard to the predisposing causes, the first discussed is the ques- 
tion of hereditary influence. The doctrines entertained by Mr. Laurence 
on this subject can readily be gathered from a few quotations. 

" The popular idea is, as medical practitioners must be well aware, that 
hereditary predisposition exercises an unusually baneful influence in the 
production of cancer ;" but, " on the whole, I am inclined to regard this 
particular in the aetiology of cancer as of little or no value in a diagnostic 
point of view." 

The following summary is presented, subsequently to a very interesting 
tabular statement of the "comparative mortality of cancer and phthisis in 
London in the years 1845 to 1850:" '' Hence the average annual mor- 
tality in London from cancer in both sexes, from the age of 25 to 80, and 
from phthisis from the age of 5 to 65, is respectively 796.5 and 6040 ; and 
the ratio of the average mortality of cancer to phthisis is 1 — 7.5. Now I 
contend that, if cancer is less than one-seventh as fatal as phthisis, this 
fact alone is sufficient to render it highly probable that cancer, as a rule, 
is not an hereditary disease.''^ 

Nevertheless, "that an hereditary taint does sometimes exist cannot 
possibly be denied." "M. Lebert states that 'he sought with much care 
for hereditary predisposition in 102 cases, and found it in 14 of these pa- 
tients.' In 49 cases, which I have observed myself, and in which I have 
specially noted the point, I find 7 cases of an apparent hereditary predispo- 



1859.] 



Laurence, Diagnosis of Surgical Cancer. 



173 



sition to cancer." "This proportion is too small to establish the here- 
ditary nature of cancer." Yet, small as it is, it must be received with 
caution ; for " the bare statement of a patient that one of his relatives 
died of cancer, is not sufficient evidence to the pathologist that such was 
really the case." 

Having thus decided to reject the question of hereditary influence as an 
element in forming a diagnosis, the question of the influence of sex is next 
discussed, and while admitting that the large majority of cases occur in 
females, yet regarding this to be due to the fact that the female breast and 
the uterus are favourite seats of cancer, the doctrine is propounded that, 
" however significant the influence of sex may be in the natural history of 
cancer, its diagnostic value becomes entirely lost." 

Age, on the other hand, is regarded as an important element in the diag- 
nosis, provided it be considered in connection with the locality of the 
tumour. " Supposing we are told that a female has a tumour in the breast, 
and nothing more ; from this we can infer nothing. Supposing, again, 
we are told a female with a tumour somewhere is aged fourteen : from this 
we can infer nothing. But let us be told that that ' somewhere' is in the 
breast, and we at once, exteris puribus, derive a most important conclu- 
sion, viz : that the chances of the tumour being of a cancerous nature are 
infinitely small." 

" The previous health of the patient gives us but little information. As 
a rule, it will be found that cancerous patients have been otherwise remark- 
ably free from disease." In this connection the vexed issue of the possible 
coexistence of cancer and tubercle is discussed, and while the opinion is 
expressed that this complication is rare, the details of three cases are given 
in which the coexistence is stated to have been observed by Mr. Laurence. 

The exciting causes, so called, are considered to be too equivocally 
established to be of any value in forming a diagnosis. With regard to the 
" special previous history, attention is first drawn to the progress of the 
growth. Malignant tumours, as a rule, grow more rapidly than benignant. 
But if too much stress be laid upon this fact, it will mislead ; for while some 
innocent tumours run a very rapid course, some cancers progress very slowly. 

Loss of flesh, which, "with exhausting sweats, derangement of the 
digestive organs, and a peculiar waxy tint of the countenance, form to- 
gether the principal elements of the so-called ' cancerous cachexia,' " is 
often wanting ; " in the early stages of their disease, patients often pre- 
serve their embonpoint in all its integrity." 

As to the condition of the patient when first brought under observation, 
the " local phenomena^'' naturally demand the first consideration. Scirrhus 
and encephaloid receive separate consideration in this connection. The 
stony hardness, smaller size, and nodulated surface of scirrhus, its compara- 
tive fixedness, the dimpling and discoloration of the skin, &c. &c., are 
here discussed. The greater bulk and " elastic resilient feel" of encepha- 
loid are insisted upon ; and some curious cases are given illustrating the 
possibility of confounding a softened encephaloid with an abscess, and vice 
versa. " This is a less dangerous error than its reverse, that of taking an 
abscess for a tumour." " Roux, Sir Astley Cooper, Liston, have all done 
it, and I have myself seen a breast amputated for a supposed tumour, 
which turned out after the operation to be only a small chronic abscess." 
We fully agree with Mr. Laurence in the practical deduction, that the use 
of the grooved needle should always precede the knife, except in the most 
palpable cases. 

No. LXXIIL— Jan. 1859. 12 



174 



Reviews. 



[Jan. 



As the disease progresses the tumour presents at some point the cancer- 
ous ulcer or fungus, the characters of which are next discussed, with some 
remarks on the tendency of malignant growths to slough. A few para- 
graphs referring to hemorrhage, pain of an intermittent character, and the 
enlargement of neighbouring lymphatic glands, complete the chapter, and 
with it the survey of the clinical facts which bear on the diagnosis of ex- 
ternal cancer. 

The third chapter is devoted to the anatomy of cancer, in which, after a 
short su-rvey of the appearances presented to the naked eye, the question of 
the microscopic characters or minute anatomy of the growths is discussed. 
And here, indeed, is the vexed question in the diagnosis of cancer ; some 
rejecting minute structure altogether as of no value in a diagnosis, others 
admitting the importance of a study of the minute anatomy of the growth, 
but variously divided as to the characters on which an opinion is to be 
based. Mr. Laurence appears fully aware of the real value of the micro- 
scope in these cases: That it is a material aid in the solution of the nature 
of doubtful cases," he says, "cannot well be denied." 

The value of minute structure admitted, the question at once presents 
itself. What anatomical details shall be relied upon as indicating the can- 
cerous nature of the growth ? 

We are disposed to think, after a careful perusal of this work, that the 
author has hitherto chiefly directed his attention to the elementary forms 
observable in these growths, neglecting almost totally the question of the 
secondary grouping of the form elements. He gives, in his neat plates, 
numerous drawings of cells and nuclei, but no sections of either scirrhus or 
encephaloid. In view of this, his opinions on the question of microscopical 
diagnosis appear to us the inevitable sequence of the facts in his possession. 
But we believe that he would perhaps modify them much, should he turn 
his attention to the study of thin sections. 

Without intending to insist upon it as specific, he still retains the faulty 
term " cancer-cell," A term which, bad as it is, we quite agree with him 
is far better than such technical expressions as " Thnetoblast," proposed by 
M. Robin, or " Macrocyte," suggested by M. Leopold Oilier. 

The characters assigned to the cancer-cell are those so often reiterated. 
The variable size, shape, and granular appearance of the cell, with the 
large, sharply-outlined single, double, or plural nucleus, and the bright, 
large, single or plural nucleolus, upon the ^;es^c^^Zar character of which M. 
Oilier has laid such stress. 

The cell is occasionally filled with fat-globules, and transformed into a 
granular mass of variable size or shape. Bodies of this kind are found 
more or less abundantly in most cancers. Free nuclei frequently exist, and 
may compose the whole of a growth. Bundles of connective tissue are 
often observed, and the above elements, with fat-globules, the debris of 
disintegrated tissue, and j^6ro-pZas^zc cells (by which the author implies the 
cells of developing white fibrous tissue), constitute the elements of the so- 
called ''cancer-field." 

He considers that it is upon the presence of these elements, but especially 
upon the presence of the so-called "cancer-cell," that a diagnosis is to be 
founded. " In the greater number of cases of cancerous tumours the so- 
called cancer-cell will be found." At the same time, he is perplexed vdth 
the further fact, which indeed is inexplicable from his stand-point, " that 
this form of cell is occasionally seen in growths manifestly innocent." 

The grand question of the homology or heterology of cancer, command- 
ing rapidly so much attention, is,, of course) beyond the province of a work 



1859.] 



Laurence, Diagnosis of Surgical Cancer. 



115 



devoted exclusively to diagnosis. We are, however, pleased to observe in 
these pages passages which indicate a vast progress beyond the old idea of 
heterologous structure. Especially do we refer to the statement of Mr. 
Laurence, that he has observed a full series of transition forms between the 
" typical cancerous and typical fibro-plastic cells." A series of such forms 
are figured in the plates. The significance of this fact is not lost upon our 
author, who propounds in connection with it the following proposition : — 
That there do exist cell-forms, which it is difficult or impossible to 
refer either to the cancerous or fibro-plastic type exclusively; and, as a 
corollary. That the existence of such forms brings us to the conclusion, 
that the two forms of cell cannot but be regarded as the extreme links of a 
chain of forms connected by intermediate stages.^^ 

It would appear to us that the facts proclaimed in this proposition are 
in themselves alone sufficient to overturn the doctrine of heterology so long 
taught in connection with cancerous growths, and although Mr. Laurence 
does not enter into this discussion, yet his views can be inferred when we 
find him state that the facts above propounded are '4n conformity with 
the unity of natural products;" and especially when we find him quoting 
approvingly the broad proposition of Carl Wedl : The fundamental cha- 
racter of cancer is that of a malformed (aborted) and degenerating new 
formation of connective tissue." 

Entertaining such views, and studying merely the elementary forms of 
the growth, and not their secondary arrangement, Mr. Laurence's conclu- 
sion appears the necessary result of the facts in his possession when he 
says : That the results afforded by the microscope must take a position, 
but not an exclusive and overbalancing one, in the series of data which are 
to serve us as the premises for our conclusion," as to the cancerous nature 
of a given growth. 

Chapter 4th is devoted to colloid cancer, which has lately been so pro- 
foundly investigated by Rokitansky. The question of the cancerous nature 
of these growths is jet sub judice. In our present state of knowledge, it 
will be best to consider it as a form of cancer. Subsequent research may 
one day definitely settle the question." 

Chapter 5th considers the subject epithelioma, concerning which the 
opinion is expressed, that " Epithelioma is a local disease (quite distinct 
from cancer), and if it is completely removed before any affection of the 
lymphatic glands, the patient becomes permanently cured.^^ 

We forbear any lengthy comments upon this opinion, with which we 
cannot possibly agree, for although the existence of innocent epitheliomata 
is undoubted, epitheliomata resulting from the influence of the law of ana- 
logous formation upon a cancerous growth, appear to be no less well esta- 
blished. Our object in this article has rather been to present our readers 
with a succinct account of the author's views than to enter into a contro- 
versy with any of them with which we do not agree. Such a discussion 
would occupy more space than we can at present devote to it. On the 
whole, we commend Mr. Laurence's work to the favourable consideration 
of American surgeons. However we may differ from him upon certain 
points, we feel convinced that he is upon the right path. If our know- 
ledge of cancer is to be progressive, careful anatomical investigation, among 
other means of study, must not be neglected. Eor ourselves, we feel con- 
vinced that the establishment of the doctrine of the homology of cancer 
which Carl Wedl proclaims, and at which Mr. Laurence hints, will open a 
new era in the study of pathology. J. J. W. 



Reviews. 



[Jan. 



Art. XY. — The Physiology and Treatment of Placenta Prsevia. Being 
the Lettsomian Lectures on Midwifery for 185t. By Robert Barnes, 
M.D., F. S. S., &c. &c. London: John Churchill, 1858. 12mo. pp. 208. 

The difficulties attendant upon the management of cases in which the 
placenta is attached to the cervix uteri, the diversity of views held by prac- 
titioners of acknowledged experience as to its proper conduct, the high 
mortality which has everywhere been found to attend it where the records 
of a large number of deliveries can be consulted, and the importance of the 
interests at stake, invest with unusual interest every suggestion calculated 
to throw light upon the physiology of placenta praevia, or its successful 
treatment. 

Dr. Barnes has been for some time favourably known by his contribu- 
tions to the pathology of the placenta. The present volume is devoted to 
the exposition of certain original views in relation to the physiology and 
treatment of placenta prsevia, which are introduced by a sketch of the doc- 
trines generally taught. 

Nearly all the older writers recognized the attachment of the placenta to 
the cervix, though some considered it as having been accidentally detached 
from the fundus and fallen down ; and they taught, with more or less dis- 
tinctness, the necessity of delivery by turning. Puzos, having more confi- 
dence than his contemporaries in the powers of nature, advised the excite- 
ment of uterine contractions by irritating the os by the finger, followed by 
a rupture of the membranes as a means of terminating the hemorrhage, and 
left the case to nature. Rigby, unaware that others had entertained and 
even published similar views, announced as the result of his own observation 
that the attachment of the placenta is to the internal surface of the os uteri, 
and that, when thus placed, hemorrhage is unavoidable; that these cases 
differ essentially from those of accidental detachment from the fundus, and 
hence he drew the distinction of unavoidable and accidental hemorrhages, 
the one demanding early delivery, the other seldom requiring it. 

Our author proceeds to cite the opinions of more recent authors, in which 
the unavoidable character of the hemorrhage and the necessity of artificial 
delivery is distinctly avowed. Thus, Dr. Collins says : "We may conclude 
that where the placenta is fixed over or near the os uteri, nothing but de- 
livery will put a stop to the loss of blood." Also, Ingleby says: "Pain, 
efficacious as it is in the accidental form of hemorrhage, unless adequate to 
the expulsion of the child, is neither to be expected nor to be desired to any 
material extent in the unavoidable form, as it only renders the effusion more 
abundant." 

"By all these authors it is assumed as law," says Dr. Barnes, "that the hemor- 
rhage is in direct ratio to the activity of the labour. It is assumed that the 
cervix cannot expand without causing hemorrhage. This assumption, partly 
true, involves a fundamental error or oversight." 

These are unquestionably the doctrines and practice which have prevailed 
during the past hundred years. Since the publication of Puzos' memoir 
in 1*743 we know of no author who has taught that simple rupture of the 
membranes and the encouragement of the expulsive efforts of the womb 
afford the best chance in cases of complete cervical attachment, though in 
cases of partial attachment this has become the established rule of practice. 



1859.] 



Barnes, Placenta Praevia. 



A few years since, Prof. Simpson proposed an expedient, which, though 
designed as a resort only in exceptional cases, has been by many designated 
as the "new treatment." It is true that Mr. Kinder Wood and Mr. Rad- 
ford had both successfully adopted this plan; but, whether this fact was 
known to Prof. Simpson or not, to him is due the merit of first offering it 
to the profession, accompanied by facts of sufficient number and importance 
to challenge a thorough examination of its merits. Finding that in nu- 
merous recorded cases of placenta praevia, in which the placenta had been 
spontaneously expelled before the birth of the child, the flow of blood had 
at once ceased. Dr. Simpson proposed artificial detachment as a remedy for 
those cases of alarming hemorrhage in which delivery is impossible or un- 
advisable. Incidentally connected with this proposed practice was the theo- 
retical dogma that the hemorrhage in cases of this accident proceeds chiefly 
from the mouths of the placental vessels, and not from the exposed surface 
of the uterus. The plan, thus fortified by the doctrine of the placental 
source of hemorrhage, from which, if true, it seemed quite clear that arti- 
ficial separation must necessarily put an end to the loss of blood, enlisted 
the attention of the entire profession. 

The practice has been adopted in not a few instances, and the results 
reported in the medical journals. In his prize essays on placenta praevia, 
Dr. Trask has presented the collective experience of the profession on this 
subject, so far as it could be learned from reported cases ; and the result of 
the inquiry confirms the assertions of Dr. Simpson, and renders it very 
clear that artificial detachment of the placenta may be relied upon as a 
generally effectual means of terminating the hemorrhage, subject to the dis- 
advantage that the life of the child is almost necessarily sacrificed by the 
destruction of the placental connection with the mother. The design of 
Dr. Simpson's recommendation has been misapprehended by those who have 
delivered by turning immediately after separating the placenta, inasmuch as 
this operation was proposed only for cases in which turning could not be 
safely performed. The plan of artificial detachment may be regarded, there- 
fore, as. one of the expedients at present resorted to for the management of 
the most hazardous cases of this accident. 

The views presented by Dr. Barnes as new, and as furnishing a more 
correct explanation of the physiology of the accident in question, and a 
more rational treatment, may be briefly stated as follows : Uterine contrac- 
tions, so far from being deprecated in labours complicated with placental 
presentations, are to be encouraged as the agency upon which the patient's 
safety depends. In every case there is a point up to which the separation 
of the placenta will take place, and beyond which it will not proceed; which 
being attained, hemorrhage will spontaneously cease. In cases of extreme 
urgency, a partial separation by the hand, to the extent to which it would 
take place could labour proceed without extraneous interference, will secure 
all the benefit claimed for entire separation of the organ, with the great 
advantage that it allows a continued connection between the mother and 
the foetus through the undetached portion of the placenta. 

We propose briefly to examine the grounds upon which these doctrines 
are based, and the practice recommended. "What is the course of a labour 
complicated with cervical or central attachment?" The prevailing doctrine 
is that there is an essential difference between the circumstances attending 
the separation of the placenta from the fundus and its detachment from the 

' See Transactions of tlie American Medical Association for 1855. 



1Y8 



Reviews. 



[Jan. 



cervix ; that the separation from the fundus occurs without hemorrhage, and 
that from the cervix with hemorrhage, which is unavoidable ; that contrac- 
tions of the womb, which in fundal attachment secure against flooding, in 
cervical attachment necessarily cause flooding. This doctrine Dr. Barnes 
regards as physiologically erroneous. 

If we watch a case of placenta praevia which does not require the inter- 
ference of art, we observe that every contraction of the longitudinal fibres 
of the womb, by which the lower segment of the womb is drawn upward 
and the os uteri opened, is accompanied by a gush of blood, which ceases 
as the contractions subside, and that the successive contractions are accom- 
panied by successive discharges of blood, with intervals of freedom from 
hemorrhage, until at last, if the child has not been first expelled, a stage 
arrives when the recurrent contractions of the womb do not entail further 
flooding," and hemorrhage ceases. Other authors have remarked this cir- 
cumstance. Our author quotes, by way of illustration, several cases from 
Dr. Lee and others, in which hemorrhage spontaneously ceased before the 
birth of the child. The question arises, why does hemorrhage in these cases 
cease? The prevailing opinion is that the presenting part of the child, 
under uterine contractions, acts as an internal plug for the bleeding vessels; 
to which our author objects that "bleeding has often ceased before the mem- 
branes were ruptured, and consequently before the child was brought into 
contact, by pressure, with the neck of the womb." 

Our author cites at length a case reported by himself, in which report, as 
he believes, the true physiology of the accident was for the first time unfolded. 
In this case of partial presentation the hemorrhage ceased after the employ- 
ment of the tampon, under a presentation of the feet, the membranes being 
intact. "The detached portion of the placenta had become plugged up by 
coagula, and the remainder, being attached to the body of the uterus, was 
not liable to become separated during the contractions of that organ," and 
the case was resolved into one of natural labour so far as the placental 
attachment is concerned. Dr. Barnes maintains that the placenta is cast 
oif from the cervix, in concentric zones or rings if the case be one of pla- 
centa centralis, and in segments of rings if it be a partial presentation. 

"Zone after zone is bared by recurring contractions, and necessarily sealed up 
until that physiological limit, that line of demarcation between normal and abnor- 
mal placental implantation, the boundary-line of placental detachment which I 
claim to have discovered, has been reached. This zone attained, the labour is a 
natural labour !" 

It is not, says Dr. Barnes, the "separation of the placenta which secures 
immunity from flooding, but the contractions of the womb." Dr. Barnes 
quotes the very pertinent views of Sir Charles Bell relating to the mus- 
cularity of the womb; they are in fact, says our author, the anatomical 
foundation of the physiological views which he seeks to enforce. Our au- 
thor divides the superficies of the uterus into three zones : the fundal zone, 
the seat of usual and safe placental attachment; the middle zone, the seat 
of lateral attachment; and the cervical zone, or the seat of dangerous pla- 
cental attachment; the boundary-line between this last and the middle zone 
he terms "the lower polar circle," or the "limit of spontaneous placental 
detachment." Below this boundary -line we have spontaneous placental 
detachment, with hemorrhage; above it, spontaneous separation, and ex- 
emption, for the most part, from hemorrhage. 

The position of the lower polar circle, or boundary-line between hemor- 
rhage and safety, our author considers to correspond with the line occupied 



1859.] 



Barnes, Placenta Prjevia. 



179 



by tlie OS uteri when sufficiently expanded to allow the passage of the full- 
grown foetal head, which, by measurement, he finds to be about three inches ; 
so that "if we describe a circle within the womb, at three inches distant from 
the OS, * * * we shall have the boundary-line between hemorrhagic and 
non-hemorrhagic placental attachment," Confirmatory of this, we find, on 
examining the placenta after its expulsion, that the portion which had been 
adherent within the cervical zone is infiltrated with coagulated blood, pre- 
senting a different appearance from that which had remained attached above 
the line, and which had been detached after expulsion of the child; and this 
part, according to our author, usually measures from three to four inches in 
depth. Our author expresses the belief that this boundary-line of safety is 
often practically reached, and the hemorrhage stopped, when the os has not 
opened wider than a wineglass, from the distension by the bag of membranes 
under expulsive pains. He next considers the two classes of cases in which 
partial detachment of the placenta may be artificially resorted to, viz., those 
of undilated os uteri, and those of extreme prostration, the classes in which 
total detachment has been recommended. Our author's reprobation of forced 
delivery in cases of undilated cervix meets our hearty concurrence. Though 
sanctioned by some eminent authorities, it was characterized by Dewees as 
an "outrageous practice;" and he declared that during his practice of thirty 
years the indications, so far as he had witnessed, were "readily met by the 
use of the tampon and other auxiliary remedies." 

The value of total detachment is next considered. He expresses the 
belief that in the reported cases of this operation, hemorrhage ceased not 
because the whole placenta was separated, but because the separation had 
reached that physiological limit which he has pointed out. Of this he 
offers no proof, except that in some of the cases hemorrhage had ceased 
before the placenta was wholly detached. He finally says: "We are 
amply justified in concluding that the artificial detachment of the placenta 
cannot be relied upon to arrest the hemorrhage." Now, without stopping 
to discuss the point which we consider satisfactorily settled by the re- 
searches of Dr. Trask, in which it is shown that, of sixty-six cases, in 
thirty-five hemorrhage ceased "immediately and entirely," and in a large 
proportion of cases hemorrhage ceases " either at once and entirely * * * 
or within a short time, and that if it continues at all, it is but to a trifling 
degree" — we cannot but express our surprise that our author should seek 
to throw discredit upon a procedure which certainly embraces his own plan; 
for if total separation is inadequate to suppress hemorrhage, it seems diffi- 
cult to understand how a partial detachment should accomplish this end. 

In the partial detachment of the placenta from within the cervical zone, 
we have, according to our author, a remedy adapted to cases in which 
" ordinary means are impossible or dangerous." 

It cannot be denied that the plan of Dr. Barnes, should its promises be 
realized, presents great advantages over the entire separation of the pla- 
centa both in ease of performance and in the superior chance afforded the 
child. 

Dr. Cohen, of Hamburg, has proposed a somewhat similar course, with- 
out recognizing the physiological doctrine upon which that of Dr. Barnes 
is based. Dr. Cohen advises that in those cases where the symptoms are 
too urgent to allow us to trust the case to nature, we are to convert the 
case from a central to a lateral placenta. To accomplish this, we are di- 
rected to find out on which side of the uterus the greatest bulk of the 
uterus is situated, and to feel for the edge of the placenta upon the side 



180 



Reviews. 



[Jan. 



opposite to this, then tear the membranes freely from the border of the 
placenta and sweep the finger round half the circumference of the os uteri, 
so as to detach the placenta completely from that side of the uterus occu- 
pied by the smaller portion of the placenta. The uterus expands, the de- 
tached portion of placenta drops down by the side of the presenting part 
and is compressed by it, and hemorrhage is suppressed. Dr. Cohen afiirms 
that he has often practised this with success, having never lost a mother, 
and seldom a child. This is precisely what occurs in partial presentations, 
when the membranes are ruptured after more or less spontaneous separa- 
tion. In the very instructive series of cases of placenta prsevia published 
by Dr. Radford, and republished in this Journal, April, 1856, a case is 
reported which occurred in 1826, in which Dr. Radford performed the very 
operation recommended by Dr. Cohen. Under increase of pains the de- 
tached portion " took a lateral position, allowing the child to pass by, and 
which was born alive in about three hours." Dr. Radford remarks : "I 
detached the placenta as freely as I thought necessary for the passage of 
the child, as it is better systematically to do this, rather than risk the tear- 
ing of the placenta," &c. This operation was performed in several other 
cases reported by Dr. Radford. In cases of central placenta, Cohen's plan 
must often be adopted to afford an opportunity for the passage of the 
child. Whether the plan of Cohen or that of our author is followed, in 
either case active contractions of the womb are indispensable to the safety 
of the patient. To this end, while the plug is used to favour coagulation, 
friction of the abdomen, a firmly applied bandage, ergot, &c., must be re 
sorted to, and in the failure of these, galvanism may be employed, which 
our author affirms rarely or never fails. 

Whatever may be thought of the reasonableness of the views here pre- 
sented, they are susceptible of being tested by experiment ; and had the 
publication of this book been delayed until it could have been fortified by 
a series of cases in which the operation had been performed, a more intel- 
ligent judgment could be formed. Our author has chosen to depend upon 
the arguments drawn from the sources indicated, rather than to wait for an 
accumulation of facts in support of his views. Total separation of the 
placenta has been put to the practical test, and has proved successful in 
accomplishing the great object for which it is employed, with the very 
serious disadvantage, however, that it almost necessarily entails the de- 
struction of the child. If partial separation, as recommended by our author, 
will accomplish the same good, and yet secure to the child the means of 
sustained existence, it will prove an invaluable boon. We have sought in 
vain in the medical journals. for the record of any trials of this method ; it 
remains to be seen if it will accomplish this good. Our author provides 
for the contingency of its failure by suggesting total separation as a last 
resort, though he has previously expressed a belief that it cannot be relied 
upon. 

In the appendix are a number of cases, original and selected, in which 
hemorrhage had existed, but ceased spontaneously before dehvery of the 
child, from which circumstance our author argues that the doctrine that 
hemorrhage in cases of placental presentation is unavoidable, is untrue, and 
leads to serious errors in practice. 

Under the prevailing dogmas the arrest of hemorrhage inspires no hope in 
the heart of the accoucheur. He is taught to believe that it will unavoidably 
return ; he hastens to deliver, and the poor woman, who had reached the haven 
of safety, is destroyed by the operation, a victim of the 'nimia diligentia 
medici,' " 



1859.] 



Barnes, Placenta Prsevia. 



181 



There follow two cases in which the placenta was partially detached by 
the hand. One is reported by Dr. Simpson, as of probable entire separa- 
tion, which our author claims, and which very probably was but partial 
detachment ; the other a case occurring to our author himself at the sixth 
month. 

The alleged discovery of our author that hemorrhage ceases in the cases 
above referred to because a certain degree of dilatation is reached beyond 
which separation is no longer induced, is not, we think, clearly established, 
though his views must be regarded as very ingenious, and calculated to give 
precision to our knowledge and practice. The character of the evidence 
upon which he relies is, to a certain degree, the same that he has justly 
criticized in the paper of Dr. Simpson on total detachment. He relies upon 
the fact that hemorrhage sometimes ceases spontaneously before the birth 
of the child. Dr. Trask has shown a very essential difference between 
labours in which the placenta was spontaneously expelled before the birth 
of the child, and those in which it became subsequently detached. In the 
first class the child also was born by the unaided efforts in 51 per cent, of 
the cases, while in the latter class spontaneous delivery occurred in only 17 
per cent. " The only explanation that can be given is, that cases in which 
the placenta is expelled before the birth of the child, as a class, are charac- 
terized by a tonicity of the womb and a vigour of uterine contraction which 
we do not find in ordinary cases of this accident." In the cases of sponta- 
neous arrest of hemorrhage quoted by our author, it is highly probable the 
labours were of a similar character, and we see the risk of assuming upon 
such a basis that a partial artificial separation will arrest the fl^ow. 

Although our author attaches but little importance to the amount of 
hemorrhage proceeding from the separated portion of placenta, but believes 
that the principal source of bleeding is the exposed mouths of the uterine 
arteries upon the uterine walls, it is by no means clear that the hemorrhage 
in these cases does not depend in a very important degree upon the pla- 
centa. Great stress is laid upon the consolidated, indurated condition of 
the detached portion of placenta. The experiments of Dr. Dalton (see 
Amer. MpA Monthly, July, 1858), seem to demonstrate that there is a 
free intercommunication of all parts of the maternal portion of the placenta. 
The uterus of a woman who had died undelivered was removed and placed 
under water. Air introduced through a blowpipe into the mouths of the 
divided vessels of the uterus passed freely through every part of the pla- 
centa, and escaped in bubbles on making punctures in any portion of the 
transparent chorion. Now, although the detached portion of placenta 
may, after the lapse of time, on its delivery, be found infiltrated with coagu- 
lated blood, and refuse, as in the experiments of Mackenzie and Sharpy, to 
allow the escape of blood injected through the hypogastric arteries, it by 
no means follows that the vessels were thus impervious immediately upon 
the separation of the detached portion of placenta. Indeed, the more rea- 
sonable view seems to be that during a pain, when hemorrhage is* most 
active, the bleeding is to a large extent through these vessels, the womb at 
that time being acknowledged to be in a state of active contraction ; he- 
morrhage is kept in check between the pains by tonic contraction of the 
womb, and by coagulation in the separated portion of placenta which 
sooner or later takes place. The peculiar cellular cavernous or reticular 
structure of the placenta is well adapted to favour coagulation. 

Whether the proposal of partial detachment prove in practice adequate 
to suppress alarming hemorrhages or not, the work of Dr. Barnes may be 



182 



Reviews. 



[Jan. 



read by all practitioners with great profit. With a confidence in the re- 
sources of nature, the result of a careful study of the processes by which 
he believes the various steps of labour accomplished, he thus speaks in her 
behalf : — 

" Nature declares and pronounces emphatically that the hemorrhage is not in 
all cases unavoidable and progressive in proportion to the dilatation of the mouth 
of the womb. She protests against the assumption that, in this great emergency, 
she is altogether at fault, and powerless to arrest the flooding. Let not those 
who have never had the courage to trust her, the patience to observe her, or the 
skill to interpret her, too confidently deny her power" — p. 40. 

In cases of partial presentation we know that nature most generally 
proves equal to the emergency, and effects spontaneous delivery; and this, 
we must believe, would always be the case could the bleeding be kept in 
check until the os uteri is dilated. Delivery by turning is regarded by 
every well-informed practitioner as an evil to be deprecated. How much 
encouragement is offered in the assurance, should it prove well founded, 
that after a certain degree of dilatation hemorrhage spontaneously ceases, 
and a spontaneous delivery may be expected. How to accomplish this 
temporary arrest is the great problem. Tnat it may, in many instances, 
be accomplished by the tampon, experience amply shows; repeated exam- 
ples of its successful employment will be found in the cases of Dr. Radford, 
already referred to ; these form a most instructive series which, in connec- 
tion with this subject, we advise our readers to consult afresh. 

The diversity of opinion in regard to the value of this remedy must de- 
pend upon the difference of manner of its employment. Dr. Lee, in speak- 
ing of cases of rigidity of the os, says : — 

"The tampon or plug has no power to restrain hemorrhage in such cases, nor 
do I know of any other means — either cold, quietness, or opium — which effect- 
ually have, and it is sometimes absolutely necessary to deliver by turning before 
the hand can be possibly introduced into the uterus without producing fatal con- 
tusion and laceration of the soft parts." 

In this we think Dr. Lee differs from most practical accoucheurs. We 
are satisfied from our own experience, that success in the use of the tampon 
depends upon its thorough and efficient application. The pieces of sponge 
or strips of linen should be successively introduced until the vagina is com- 
pletely filled, a compress placed over the vulva, and the whole confined by 
a X bandage, and a dry folded sheet placed beneath the hips. The least 
return of bleeding can thus be readily detected, and the dangerous oozing 
which sometimes undermines the patient without the knowledge of the at- 
tendant, may be guarded against. We have completely succeeded by first 
introducing a full-sized tubular speculum, packing it with the plugging 
material, after the ordinary mode had failed to arrest the bleeding. Dr. 
Radford, in addition to the plug, attaches much importance to compres- 
sion pf the abdomen, by a broad bandage which he calls a "retaining band- 
age,"' passed around the body, one end being attached to the bedstead, and 
the other tightly drawn by an assistant. It has been objected to the use of 
the plug in the early months, that its presence tends to induce premature 
labour, whereas we ought to try to conduct the case to full time. This is 
a matter of no little importance, but we are of the opinion that this result 
is not to be regarded as necessary or general. 

Dewees did not so regard it, and the cases of Radford exhibit proof posi- 
tive to the contrary. 

Prof. Miller, in his System of Obstetrics, advocates with great earnest- 



1859.] 



CoRViSART, On a Function of the Pancreas. 



183 



ness and ability the substitution of Puzos' method slightly modified, in 
place of artificial delivery; this method consisting in originating expul- 
sive contractions of the uterus by the tampon or plug, and then punctur- 
ing the membranes, relying on the tampon to control the flooding until the 
liquor amnii is evacuated." 

If the plug prove inefficient, and the hemorrhage continues, our author's 
plan of partial separation may be resorted to, and if it fail, we have total 
separation as a resource which will rarely fail to arrest the flow of blood. 
But in every class of cases, if our author's views be sound, we have the 
encouragement that the hemorrhage is not strictly unavoidable, as gene- 
rally understood — that it will not necessainly continue until delivery, but 
that if we can keep it in check until a certain degree of dilatation is reached, 
and sustain and stimulate the powers of nature, as by ergot and galvanism 
if need be, it will eventually cease, not to return. J. D. T. 



Art. XYI. — Sur une Fonction peu connue du Pancreas la Digestion des 

Aliments azotes. Par Ltjcien Corvisart. Paris, 1857-58. 
On a Function of the Pancreas hut little known. By Lucien Corvisart, 

If we except the liver and spleen, there is no organ of the body whose 
exact function has been so long veiled in obscurity as that of the pancreas. 
There are several reasons for the uncertainty which has existed, and under 
which we, in some measure, still labour in regard to the office performed by 
tlie pancreas in the economy. Not the least of these is the fact (with the 
exception of one or two anomalous instances in the cat, in the seal, and in 
certain fish of the genus salmo) of there being no reservoir for containing 
the fluid which it secretes, and, consequently, there has always been a diffi- 
culty in obtaining a sufficiency of the pancreatic juice for a thorough 
analysis. 

Bernard, whose keen sense of the true nature of experimental research 
never deserts him, has pointed out another cause for the various opinions 
which have existed relative to its composition, viz : that the pancreatic 
fluid varies greatly in its characters according as it is collected during the 
inflammatory process which follows the wound necessarily made in the 
abdomen of the animal submitted to experiment, or after the parts have 
regained their healthy condition. In the former case, the liquid is in an 
abnormal state, and not suitable for an analysis on which to form an 
opinion in regard to its physiological properties ; in the latter, it is nor- 
mal, and, consequently, capable of performing its role in the system. 

It is not strange, therefore, that from the time of rran9ois de la Boe, 
and Degraaf and Schuyl, his disciples — who contended for the acid cha- 
racter of this secretion — to Tiedemann and Gmelin — who sometimes found 
it acid and sometimes alkaline — and Bernard — who invariably obtained it 
with the latter reaction — there should have existed the most discordant 
testimony relative to its physical and chemical properties. 

But if the earlier physiologists differed as to the chemical nature of the 
pancreatic juice, they were still more at variance in regard to its use. Some 
considered it as serving to separate the chyle from the feces ; others, as con- 
tributing to modify the acridity of the bile ; others, as dissolving those sub- 



184 



Reviews. 



[Jan. 



stances wliich had not been digested in the stomach ; and Magendie, in the 
absence of reliable evidence, with more honesty than his predecessors, ad- 
mits that he is unable to specify what purpose it fulfils in the organism. 
Even at the present day, when baseless -theories do not go for facts, and 
when the spirit of experimental research has been directed to the task of 
enlightening us, physiologists are not altogether agreed relative to the 
functions of the gland under consideration. 

Three functions are now assigned to the pancreatic fluid 

1st. The conversion of starch into glucose. 

2d. The faculty of forming an emulsion with fat. 

3d. The digestion of the albuminous matters not acted upon by the 
stomach. 

The action of the pancreatic juice upon amylaceous food, whereby it is 
converted into sugar, was first pointed out by Yalentin, and may be 
considered as definitely established by many recent experimenters. The 
faculty of forming an emulsion with fat, and thus promoting its absorption 
by the lacteals, though surmised by Eberle, was never distinctly and promi- 
nently brought forward, till Bernard commenced his investigations. Ber- 
nard's doctrine, though opposed by Lehmann, Frerichs, Bidder and 
Schmidt, Lenz, and others, has been too frequently verified by the experi- 
ments of Jackson, Jones, and numerous other physiologists, to be dis- 
carded, and it may, therefore, be considered as admitting of but little doubt, 
that one of the most important actions of the pancreatic liquid is that sus- 
tained by the industry and genius of Bernard. 

Purkinje and Pappenheim were the first to . suggest the theory that the 
pancreatic fluid served the purpose of digesting the nitrogenous matters 
which have escaped the action of the stomach. 

Bernard and Barreswil also hold the opinion that the acidified pan- 
creatic juice is capable of dissolving the proteinaceous substances taken as 
food. According to the former, the bile precipitates these matters from 
their solution in the gastric juice, and they subsequently, coming into con- 
tact with the pancreatic fluid, are redissolved. These actions of the bile 
and pancreatic liquid also take place with the amylaceous substances, but 
in this case the latter secretion remains alkaline, whilst, with the albumi- 
nous matters, it becomes acid. 

Within the last two years, this latter theory has become intimately 
associated with the name of M. Corvisart, in consequence of its advocacy 
by this physiologist, through the columns of one of the medical journals of 
Paris and before the French Academy of Sciences. The memoir now pub- 
lished is, however, the first time that his views have been presented in a 
complete form ; and, though they may not be supported by what we regard 
as conclusive evidence, yet coming as they do from one of the most eminent 
of the French physiologists, they are entitled to a respectful and attentive 
consideration. We propose, therefore, briefly to review some of the main 
points of the theory advocated by M. Corvisart, to notice the experiments 
upon which it chiefly rests for support, and to call attention to the facts 
which militate against it. 

The theory advocated by M. Corvisart, as we have already stated, is, 
that the pancreatic juice possesses the faculty of digesting those nitrogenous 
substances which have not been acted upon by the stomach, and that it 
exercises this function not only exteriorly to the body, but also within the 
animal organism. 

The first section of the memoir is devoted to the consideration of the 



1859.] CoRViSART, On a Function of the Pancreas. 185 



action of the gastric juice on the albumen of the egg. It is here stated 
that this secretion dissolves a third of its weight of egg albumen, renders 
it incapable of coagulation, and transform it into albumen-peptone. We 
shall not stop, at present, to question the entire correctness of this propo- 
sition, but proceed to the next paragraph, which relates to the action of 
the pancreatic juice on albumen. 

A single experiment on the living subject is adduced under this head. 

" In a young and large dog, weighing fifteen kilogrammes [about thirty-three 
pounds], which had fasted twenty-four hours, I opened, without injuring the 
pancreas, both ends of the duodenum, and carefully washed out the juices, &c., 
from the intestine with a stream of water +38° 0. I then intercepted all com- 
munication with the stomach by a ligature, and, by the inferior opening, I intro- 
duced into the duodenum 78 grammes [about 1200 grains] of boiled white of 
egg. I then closed the opening by a ligature. There was still some food in the 
stomach. 

Eighteen hours afterwards, the animal was killed by strangulation. 

" The pancreas was perfectly white, and of normal appearance. It had not 
been injured by the operation, nor obstructed in its circulation. 

" The duodenum between the ligatures was very red, and distended by a liquid 
that strong pressure could not force out. The organ was opened and completely 
emptied of its contents ; that is, of several pieces of softened albumen floating in 
325 cubic centimetres [nearly 10 fluidounces] of an alkaline liquid, from which 
a light flaky precipitate was slowly thrown down on standing. 

" The insoluble substance was collected and filtered, completely dried, and 
weighed. It amounted to 3 grammes 55 centigrammes [about 55 grains], re- 
presenting about a third part of the dry albumen ingested. 

"The duodenum had, therefore, dissolved nearly 50 grammes [775 grains] of 
the moist white of egg which had been placed therein." 

It is then stated that, making allowance for the water taken into the 
duodenum with the albumen, at least 250 cubic centimetres (7|- ounces) of 
secreted fluid had entered the intestine. In a note, it is further asserted that 
bile was tested for by nitric acid, and not discovered to be present, and 
that the quantity of intestinal fluid must have been exceedingly small. The 
inference accordingly follows that, in eighteen hours, 250 cubic centimetres 
of pure pancreatic juice had dissolved 50 grammes of moist white of egg, 
equivalent to 3.55 grammes of the dry substance. 

There are several objections to be urged against the deductions drawn 
from this experiment. M. Corvisart contends that the pancreatic juice, 
unmixed with bile or any other substance, possesses the faculty of dissolv- 
ing albumen. We do not think this experiment establishes his view. In 
the first place, we think he has undervalued the quantity of intestinal 
liquid present. Now Bidder and Schmidt and others have established, 
beyond doubt, that the intestinal juice possesses, in an eminent degree, the 
property of dissolving albuminous substances. As we have no reliable 
data relative to the quantity of intestinal juice secreted in a given time from 
a known surface of intestine, we are unable to say how much of the 250 
cubic centimetres of liquid found by M. Corvisart consisted of this fluid ; 
but, if we may judge from the experiments of Bidder and Schmidt — who 
from a large dog, weighing 20 kilogrammes, obtained, in 8 hours and 15 
minutes, but 7.860 grammes of pancreatic juice, and from a strong man, 
weighing 64 kilogrammes, but 150 grammes in 24 hours — we should be 
still less disposed to attach much value to M. Corvisart's conclusion. 

In the second place, there is no certainty that bile was not an important 
agent in effecting the solution of the albumen, and, if absent at the time 
the post-mortem examination was made, it may have been present and un- 



186 



Reviews. 



[Jan. 



dergone resorption, as M. Corvisart himself admits. Besides, we are far 
from being sure that it was not present when the examination was made. 
M. Corvisart informs us that he tested for bile with nitric acid, and ob- 
tained negative results. Now, the applicability of nitric acid as a reagent 
for the discovery of this secretion depends entirely upon its reaction on the 
colouring matter. As this is not a fixed quantitative constituent of the 
bile, the test is objectionable, and we therefore find that, when the colour- 
ing matter is present in but small quantity, nitric acid fails to indicate bile, 
even though the latter may exist in considerable proportion. The bile, also, 
may be so materially altered within the body, that the nitric acid entirely 
fails to discover it, no matter in how great quantity it may be present. 
We are unable to conceive why M. Corvisart omitted to make use of Pet- 
tenkofer's test, which is altogether more delicate and reliable than the one 
he employed. 

The above remarks apply, of course, only to the experiment we have 
cited. In a subsequent experiment, M. Corvisart tied the common duct, 
and thus prevented the entrance of bile into the intestine. The intestinal 
juice, however, could not be prevented access to the albumen, and doubtless 
exercised its ordinary influence. 

These are the only experiments performed with reference to the action 
of the pancreatic fluid by M. Corvisart, on living animals. 

M. Corvisart objects to the method of experimenting with the pancreatic 
juice by obtaining it direct from the pancreas by a fistula, as practised by 
Tiedemann and Gmelin, Bernard, Bidder and Schmidt, and others. He 
employs, instead, an infusion of the pancreas in water. For this purpose, 
he takes the fresh gland, cuts it into small pieces, and exhausts it with 
water. The liquid thus obtained he finds possesses the property of dissolv- 
ing the nitrogenous articles of food. This fact he has certainly established. 
Whether, however, the infusion of the pancreas is to be regarded as equiva- 
lent to its secretion, is, we think, exceedingly doubtful. M. Bernard found 
that the infusion of the pancreas was capable of forming an emulsion with 
fat, but he had previously determined that the secretion possessed the same 
faculty. M. Corvisart, on the other hand, has not demonstrated that the 
pure pancreatic juice dissolves albumen, and, in fact, Frerichs has completely 
refuted any such idea. 

We are constrained, therefore, in view of what we have advanced, to 
refuse our assent, at present, to the theory of M. Corvisart. We do not 
pretend to say that he may not be correct in his views, but we do say that 
he has not demonstrated them so satisfactorily as to cause them to be re- 
ceived as physiological truths. 

We have neither time nor space to follow M. Corvisart through the 
other divisions of his subject. The one we have commented upon is a type 
of the others, which relate to the action of the pancreatic juice on blood- 
albumen, fibrin, gelatin, casein, &c. There are a number of points of in- 
terest connected with his investigations for which we must refer the reader 
to the memoir. W. A. H. 



1859.] 



ISt 



BIBLIOGRAPHICAL NOTICES. 

Art. XYII. — A Practical Treatise on the Diseases of Children. By D. Francis 
CoNDiE, M. D., Fellow of the College of Physicians, Member of the American 
Medical Association, Member of the American Philosophical Society, etc. 
Fifth edition, revised and enlarged. Philadelphia: Blanchard & Lea, 1858. 
8vo. pp. 762. 

Fifteen years since the first edition of Dr. Condie's now well-known treatise, 
then just issued from the press, was reviewed in this journal. The able author 
of the review stated it to be his persuasion that the American medical pro- 
fession would soon regard it not only as a very good book, but as the very best 
practical treatise on the diseases of children. The long and extensive experience, 
accurate observation, and diligent study, not only of English writers, but of the 
continental and especially of the German authors, had, it was said, fitted the au- 
thor in a remarkable manner for worthily accomplishing his difficult task. For 
the practical physician, who should turn to its pages to learn all the phenomena 
which may be presented by the disease he is treating, and all the means to which 
he may resort for the cure of that disease, it was promised to offer many and 
strong attractions, amongst which were mentioned completeness, clearness, judg- 
ment, and good sense. Since then, every three years a new edition has been an- 
nounced in the bibliographical department of this journal, showing the correctness 
of the previsions of the reviewer, and the appreciation by the profession at large 
of the very best practical treatise on diseases of children. Each successive edi- 
tion has been carefully revised, and such additions made thereto as the increased 
experience or newly-acquired information of the author allowed. The volume, 
which at first contained 651 pages, is now extended to 762, and every sentence in 
the book has been again and again carefully weighed. The constant attention be- 
stowed by Dr. Condie upon this treatise, its revision, and the improvements con- 
stantly being made therein, must have cost him great labour ; but, at the same 
time, what a continual source of pleasure it must prove to an author to watch 
the growth in the favour of the profession of what is destined to make his useful- 
ness live after him, and to transmit to other generations his learning and his 
name. 

In the preparation of this fifth edition of his work, Dr. Condie tells us in his 
advertisement that — 

"The entire work has been subjected to a careful and thorough revision — a 
considerable portion of it has been entirely rewritten, and several new chapters 
have been added. 

"In the different sections will be found incorporated every important observa- 
tion in reference to the diseases of which they treat that has been recorded since 
the appearance of the last edition; and in the several new chapters an account 
of some affections omitted in former editions, and for the accurate description 
and satisfactory management of which we are indebted mainly to the labours of 
recent observers." 

We notice in this present edition that Dr. Condie regards the evil efiects of 
enlarged tonsils as *more serious than he was formerly disposed to do. It was 
taught by him that he had seldom seen much injury or very serious inconvenience 
to result from them in children ; that they usually gradually dispersed, and seldom 
continued beyond the period of puberty. It is now stated by him that "in young 
children the tonsils are subject to a chronic enlargement, the effects of which are 
far more serious than the entire neglect which the affection has met with from 
medical writers would lead us to suppose;" and that "when enlargement is 



188 



Bibliographical Notices. 



[Jan. 



once established, tlie hypertrophied tonsils never diminish in size ; their excision, 
consequently, is the only means by which the inconvenience and injury resulting 
from their presence are to be remedied." It should be added, moreover, that any 
attempt to remove the hypertrophied tonsils during childhood is strongly opposed ; 
"the operation being by no means generally successful, and it maybe productive 
of consequences more troublesome than the disease" — p. 171. 

It is particularly in the section treating of congenital affections, and accidents 
occurring most generally within the mouth, that the most important additions 
have been made. Three new chapters have here been added, treating respectively 
of cephalaematoma, intestinal hemorrhage, and cysts of the neck. 

The head of the new-born child, from the pressure to which it is subjected 
during a difficult and protracted labour, often presents a tumefaction, varying 
greatly in size and extent. This tumefaction demands scarcely any treatment ; 
absorption of the contents takes place rapidly, and the swelling quickly disap- 
pears. Occasionally, however, the same part is the seat of another much more 
important and dangerous tumefaction, called by practical writers cephalcema- 
toma. Here the effusion of blood, instead of being beneath the cranial aponeu- 
rosis, and above the pericranium, is beneath the pericranium, separating that 
membrane from the skull. In some cases, besides the effusion of blood beneath 
the pericranium, on the outer surface of the skull, there exists at the same time 
a corresponding extravasation beneath the skull, between it and the dura mater. 
A hard, sharp, abrupt ring encircling the base of the swelling in cases of cepha- 
laematoma, enables the physician to distinguish it from the tumefaction usually 
met with. The account given by Dr. Condie of this affection is exceedingly full 
and satisfactory. In regard to the cause of its formation, upon which there are 
various opinions, he believes ''that the pressure which the foetal head experiences 
in even the easiest labours, in children labouring under a peculiar hemorrhagic 
predisposition, is sufficient to produce cephalaematoma ; and without this predis- 
position the utmost pressure of the head during labour will fail to produce it" — 
p. 683. 

Of the treatment he says : — 

"In the majority of cases, cephalsematoma will do very well under a very 
simple treatment — confined pretty much to the application of cold evaporating 
washes, to hasten the resorption of the extravasated blood. The ordinary spirit- 
wash, or a solution of the hydrochlorate of ammonia in camphor-water, are among 
the best. Halmagrand recommends the hydrochlorate of ammonia in red wine ; 
others, a solution of the acetate of lead, or the acetate of zinc in rose-water. A 
slight, graduated, and uniform compression of the tumour will in all cases be 
proper. 

" The production of suppuration in the tumour, by caustic applications or a 
seton, as practised by Moscati, Goelis, and Pallettd, is a plan of treatment un- 
called for in any case, and calculated to produce greater suffering and more 
unpleasant results than, in the great majority of cases, would be liable to occur, 
even were the tumour left entirely to itself. 

"By Michaelis, Naegelfe, and P. Dubois, an early incision, for the purpose of 
evacuating the effused blood and allowing the detached pericranium to be brought 
and retained in contact with the bone, is recommended. They direct a simple 
incision to be made, extending the whole length and depth of the tumour, down 
to the bone. After the removal of the effused blood, the edges of the incision 
are to be drawn together and secured by strips of adhesive plaster ; the head 
being enveloped in a suitable bandage or cap, so adjusted as to make moderate 
pressure at the seat of the tumour. 

" But, as remarked by Bouchut, incision should be resorted to only when a 
tumour of large extent has remained stationary in size for ten or twelve days 
after its formation. * 

"Levy directs the hair to be shaved from the entire surface of the tumour, and 
for some distance around its base, and a puncture then to be made with a lancet 
at a depending point, and equable pressure exerted by the fingers, so as to expel 
as much of the effused blood as possible; afterwards a compress is to be applied, 
secured by proper straps and bandages, and kept on for about six days. 

"When suppuration occurs, and an abscess forms, this is to be treated on 



1859.] CoNDiE, Practical Treatise on Diseases of Children. 189 



general principles ; an early opening for the discharge of the pus should, how- 
ever, always be made. If the bone becomes necrosed, the dead portions should 
be removed as they become detached, and. the appropriate dressings applied" — 
pp. 683, 684. 

Occasionally a copious discharge of blood by stool, and in a few cases by vo- 
miting also, is met with in the new-born infant. It is usually within the first ten 
days following birth, though it may take place at any time within the first two 
or three months, that this intestinal hemorrhage occurs. Of the cause of this 
hemorrhage Dr. Oondie does not express any decided opinion. He says : — 

"Intestinal hemorrhage has been supposed to result in the young infant from 
the compression its body has experienced during a tedious labour; that this can- 
not be so, however, is evident from the fact that the hemorrhage has occurred 
frequently, or nearly so, after easy and rapid labours as after such as were difficult 
and protracted. Eilliet refers the disease, 1st, to the congestion of the intestinal 
tube, a condition which is normal in the new-born infant; and 2d, to some impe- 
diment to the speedy and complete establishment of respiration, in consequence 
of which the blood, unable to pass freely through the lungs, engorges the other 
organs, especially the intestines, the vessels of which, already loaded with blood, 
are unable to support this new tax. A somewhat similar explanation of the mode 
of production of the intestinal hemorrhage of the infant is given by Billard" — 
p. 692. 

The treatment recommended is "to place the patient in a cool and frequently 
changed atmosphere, to apply cold compresses to the abdomen, and to keep the 
extremities comfortably warm." Diluted alum-whey in rose-water the author has 
found to act beneficially. 

As this disease is often described and referred to under the name of melcena, 
it would have been well, perhaps, to have mentioned this fact. 

Another affection occasionally met with in children, treated of in this present 
edition for the first time, is cysts of the neck. Of the nature of these cystic 
tumours, which often increase in size with great rapidity, and by their pressure 
impede most important functions, it is said : — 

"The researches of MM. Fleury and Marchesseaux show that two distinct 
species of these cysts occur. The one being developed in the actual tissue or 
substance of the thyroid gland, and is in some instances superficial, in others 
deep-seated. This form of cystoid tumours corresponds with the cellular and 
tliyro'ideayi serous goitre of Beck and Heidenreich, the hydrocele of the neck of 
Manoir, the hydro-hronchocele of Percy, and the encysted goitre of other writers. 
The second species of cervical cyst is developed in the common cellular tissue of 
the neck, at a greater or less distance from the thyroid gland. It is the hydrocele 
of the neck of O'Beirne, the cystic tumour of Boyer and Dupuytren, the fibro- 
serous cyst of Delpech, and the hygroma cellularis of Yon Ammon and other of 
the German writers. It is the latter species which appears to be most frequently 
met with in young children" — p. 724. 

The treatment preferred by Dr. Condie is the puncture of the tumour, followed 
by iodine frictions and compression, whenever this latter can be put in practice, 
or the passage of a slender seton through the cyst. We should prefer, ourselves, 
to follow the puncture by an injection of a strong solution of iodine into the 
cavity of the cyst. 

A fact, the knowledge of which is of considerable importance to the surgeon, 
is not mentioned by Dr. Condie. When these cysts of the neck are opened by 
the trocar, both those in the thyroid glands and the other cysts of the cervical 
region, which have been shown by M. Richard to have their origin in a peculiar 
alteration of the lymphatic glands, the contents, as they escape, soon become 
tinged with blood; little by little the proportion of blood becomes more con- 
siderable, until finally it is pure blood that flows from the canula, and this flow 
of blood will continue as long as the canula is left in the interior of the cyst. 
The removal of the eccentric pressure which the contained liquid had exer- 
cised upon the walls of the cyst appears to be the cause of this phenomenon, 
which is one calculated to worry very much the mind of a surgeon not aware of 
its constant occurrence. V/". F. A. 

No. LXXIIL— Jan. 1859. 13 



190 



Bibliographical Notices. 



[Jan. 



Art. XYIII. — Diseases of the Urinary Organs. A Compendium of their Di- 
agnosis, Pathology, and Treatment. By William Wallace Morland, M. D., 
Fellow of the Massachusetts Medical Society, &c. &c. With, illustrations. 
Philadelphia: Blanchard & Lea, 1858. 8vo. pp. 579. 

Every one who adds a fact to our stock of knowledge does a service to his 
fellow-man, and he who by research collects and orderly arranges valuable scat- 
tered materials deserves his share of praise. 

Lord Bacon exhibits in his New Atlantis nine different classes of men by whose 
co-operation knowledge is to be disseminated throughout the world : 1. There are 
the merch,ants of light ; 2. The depredators ; 3. The mystery men ; 4. The pioneers 
and miners ; 5. The compilers ; 6. The dowry men, or benefactors ; 7. The lamps ; 
8. The inoculators ; 9. The interpreters of nature. If, then, a man fill well either 
of the above named offices, according to the great Bacon, he will advance the 
knowledge of society. We will not presume to designate where in the above 
classification our author stands. That he does not, in his work before us, hold a 
position among the pioneers and miners, he has told us in his preface ; for he has 
aimed simply to present a "digest" of the entire subject of urinary pathology, 
to serve as a convenient hand-book for the large class of practitioners whose 
leisure does not allow them an extended examination of authors. 

To enable him to do this, he has consulted and woven into a uniform trea- 
tise the observations of the great mass of authorities on the above mentioned 
subject. 

The book before us is a large octavo volume, got up in uncommonly elegant 
style, and beautifully and copiously illustrated. It is divided into two parts, one 
devoted to the consideration of the diagnosis, the other to the pathology and 
treatment of the diseases of the urinary organs. There is also an appendix, con- 
taining reports of interesting cases and investigations bearing upon the subject 
of urinary pathology, together with a brief but excellent description of the method 
of clinically examining the urine. 

In this part of the book the author has introduced some observations on the 
subject of diabetes, which he did not think proper to consider in the body of the 
work, as it is not a disease of the urinary organs, but an affection of assimilation. 
He quotes the observations of Drs. Hodgkin, David Nelson, Graves, and Goolden. 
The last named writer mentions the infrequency of true saccharine diabetes. 
Dr. Goolden is also quoted in reference to the frequency of saccharine urine 
without diuresis, which condition of urine he mentions as a very common affec- 
tion in cerebral and other nervous affections, and states that few cases of chorea 
and epilepsy occur in young people without betraying a trace of sugar in the 
uriiie, the sugar disappearing with the passing off of the nervous attack. 

We would add, also, another form of saccharine urine (differing from that of 
diabetes with diuresis, and which is of a pale colour), where there are not simply 
traces of sugar, but a large quantity is passed, giving rise to a specific gravity 
of 10.40. The quantity of the urine in this form is not generally much, if any, 
above the normal amount ; while, on the other hand, the colour is not unfrequently 
deeper than that of health, nor is there, as a general thing, marked thirst and 
emaciation. Again, this form of disease occurs in persons from fifty years and 
upwards, and is generally tractable to treatment. 

One remark of the author, in connection with this subject, we must be allowed 
to (juestion, viz., that when the specific gravity of the urine is above 1035," sugar 
undoubtedly exists. We have more than once had urine of a specific gravity of 
1038, and in one case it was as high as 1040, and associated with diuresis, and 
yet no sugar was present. The high specific gravity in these cases was owing to 
urea and extractive matters. 

The work, as the author remarks, is confined to the consideration of the dis- 
eases arising in or especially manifested by the organs in which the urine is 
elaborated, and temporarily retained, and the passages through which it flows, to 
that wo do not find any notice of the specific affections of these organs, nor of 



1859.] 



MoRLAND, Diseases of the Urinaiy Organs. 



191 



diabetes, the diseases of the prostate gland, or of Cowper's g-lands. A full ac- 
count, however, is given by the author of the anatomy, physiology, and patho- 
logy of the supra-renal capsules, which, perhaps, have as little to do with the 
physiology of the urinary organs as the prostate gland, and certainly their rela- 
tions are much less important in a pathological point of view. 

After some general considerations of the diflicullies in the diagnosis of the 
diseases of the urinary organs, and having made mention of the means which sci- 
ence now offers to our aid, the author passes to the enumeration of these organs, 
their "anatomical relations," their malposition, and its effects upon diagnosis. 

In the same chapter he draws attention to the importance of distinguishing 
between mere functional disturbance and more serious disease of the urinary 
Organs, and, that mistakes in diagnosis may not occur, he forewarns the practi- 
tioner to bear in mind, in his examination of a case, " the normal anatomy of the 
organs involved ; their unusual distribution ; their physiological relations ; the 
atmosphere, and its changes ; the food and drink, medicinal agents, mental emo- 
tions, restrained functions, &c." 

Having arrived in "medias res,'' the author commences with the consideration 
of the supra-renal capsules, from which we gather that the diagnosis of their 
diseases is very unsatisfactory, and their physiology unsettled. Brown-Sequard, 
the author says, " advances the hypothesis that the function of the supra-renal 
capsules is to prevent the deposition of pigment in the blood." 

In the account of the pathological conditions of these organs no mention is 
made of oily degeneration of their tissue, which condition we have seen in one 
case. 

The most interesting part of the work, perhaps, is that relative to diseases of 
the kidneys. Here we find nothing very new, but quite a full exposition of the 
knowledge of the day on this subject. The classification of Dr. George Johnson 
has been adopted, into acute and chronic desquamative nephritis, waxy degene- 
ration, non-desquamative disease, and fatty degeneration of the kidneys. 

It is unnecessary for us to enter into an analysis of the subjects here treated, 
as the ground has already been so thoroughly gone over by Dr. Johnson, in his 
work on the diseases of the kidneys. 

Bright's disease, according to the author, is synonymous with fatty degenera- 
tion of the kidneys. 

The fatty condition is, again, subdivided into two conditions — the "mottled 
fatty kidney" and the "granular fatty kidney." These two conditions are distinct 
forms of disease, and not different stages of the same affection, and, according to 
Dr. Johnson, have each a distinct history. "There is," says the doctor, "yet 
another and important distinction between the granular and the mottled form of 
fatty degeneration. In the first mentioned form of disease the formation of the 
fatty granulations is preceded by a non-desquamative disease, this being indicated 
by the condition of the urine, which is highly albuminous, clear, and without 
sediment; whereas the second form of fatty degeneration comes on very gradu- 
ally and insidiously, and frequently makes great progress before the urine affords 
any indications of the existence of renal disease. I have occasionally found a 
large proportion of fatty matter in the renal epithelium after death, in cases 
which have certainly not been attended by the secretion of albuminous urine." 

These two conditions of the fatty kidney are synonymous, according to our 
author, with "Bright's disease," the nephrite albummeuse of Rayer, the liydro- 
pisie r&nale, alhuminurie of Martin Solon, and the granular degeneration of the 
kidney of Christison. 

In the treatment of these different affections of the kidney, the author agrees 
with most of the writers of the day on this subject, in not advising the adminis- 
tration of diuretics, and speaks highly of the usefulness of active purgation with 
elaterium, especially where there are urgent brain symptoms, and refers to the 
prompt relief which follows this treatment under such circumstances. 

We can also add our mite of testimony in favour of the above statement, and 
can never forget the prompt manner in which extreme dyspnoea, caused by effu- 
sion into the chest in a case of severe albuminuria, was relieved by obtaining free 
purgation by the use of elaterium, .notwithstanding the patient seemed to be in 
a condition to contraindicate its use. 



192 



Bibliographical Notices. 



[Jan. 



The various other diseases of the kidneys, of the ureters, of the bladder, in- 
cluding cystic calculus, and the affections of the urethra, are all fully and judi- 
ciously treated of in the remainder of the work. 

In the article on vesical calculus. Dr. G-. Owen Rees's views in relation to the 
singleness of diatheses are quoted, the uric being the only true diathesis. The 
phosphatic and oxalic are but modifications or effects of it. The oxalates of lime, 
according to the doctor, are produced outside of the body, and the deposit ot 
phosphates by a diseased condition of the mucous membrane of the urinary 
passages. 

The author does not seem to believe that hereditary predisposition has any 
influence in the production of calculi ; and while we do not either believe that 
hereditary ^predisposition has much to do in moulding the material into a stone, 
yet it must have considerable influence in originating that condition of system 
which gives rise to deposits of the matter out of which they are formed. J. D. 



Art. XIX, — Illustrations of Typhus Fever in Great Britain, the Result of 
Personal Observations made in the Summer of 1853, with some Remarks as 
to its Origin, Habits, Symptoms, and Pathology . By J. B. Upham, M. D. 
Formerly Assistant Physician to the Hospitals connected with the House of 
Industry at South Boston, and at Deer Island. From the Boston Medical and 
Surgical Journal. 8vo. pp. 46. David Klapp : Boston, 1858. 

In 1852, Dr. Upham published a series of observations on "Maculated typhus 
or ship-fever, collected during the prevalence of the disease at South Boston and 
Deer Island Hospitals, in the years 1847-48, among, chiefly, the immigrants from 
on board the crowded, and often badly provided passenger ships arriving from 
different ports in Europe." 

This publication was noticed in the April number for 1853 of this Journal. It 
presented a very excellent history of typhus fever, in its different degrees of in- 
tensity, with the varying phases, complications, and sequelae, manifested by it 
during the epidemic in question ; accompanied with such views of the pathology, 
and treatment of the disease, as had been acquired from careful observation. at 
the bedside and in the dead-house. 

During the summer of 1853, Dr. Upham was presented with a very favourable 
opportunity of prosecuting his researches in respect to typhus fever, in the city 
of Dublin, as well as in the wards of the London Fever Hospital, and of com- 
paring the disease, as it presents itself in its indigenous haunts,with its manifes- 
tations and habits as an exotic, in this country. In the work before us, Dr. Up- 
ham gives from these European researches a description of the fever, intended as 
a portrait of it as it presents itself in the wards and dead-house of a fever hospital 
of Great Britain. 

As models of the disease, in its various forms of severity, as it is there met with, 
Dr. U. furnishes the minutely detailed histories of seven cases, selected from the 
practice of Drs. Tweedie and Southwood Smith. The broad and general state- 
ment of the facts developed by these cases, as examples of the ordinary forms of 
typhus fever, "in its mild, moderate, severe, and fatal" varieties, may, according 
to our author, be thus stated: "It is an aftection sudden and severe in its 
accession, originating mostly in the densely populated and poverty-stricken por- 
tions of the larger cities and "towns of England, Scotland, and Ireland ; traceable, 
in a majority of cases, on the part of the patient, to a more or less immediate 
intercourse with the sick ; common to all ages, and both sexes ; ushered in by 
lassitude, depression, rigors, anorexia, headache, pains in back, limbs, and joints, 
accompanied, or soon followed, by loss of strength, dulness of the intellect and 
special senses; perversion of memory; stupor; hot and pungent skin, dusky, 
moist, or dry ; flushed face ; suffused eyes ; furred and loaded tongue ; accelerated, 
but moderately full, soft, compressible pulse ; without any considerable deviation 
—in its simple, uncomplicated form — from a normal condition of the chest and 



1859.] 



Up II AM, Typhus Fever in Great Britain. 



193 



abdomen ; general sensitiveness of surface ; a strong, peculiar, nauseous odour of 
the body; exhibiting, on or about the fifth day, an abundant, characteristic rash, 
first seen upon the arms, upper part of chest, and legs, later on abdomen and 
back, never on the face — the approach of which is previously heralded by an in- 
distinct, mottled, and roseate appearance of the surface, seemingly subcuticular 
— which rash is at first light-pinkish, florid, isolated or clustered, simulating not 
unfrequently the eruption of measles — then darker, more or less persistent, spread- 
ing, increasing in abundance and intensity for several days, sometimes livid, 
petechial, fading on or about the tenth day, and disappearing in the order in which 
it came, from about the twelfth to the sixteenth day ; which symptoms may vary 
in severity and relative importance, may vacillate from better to worse, from worse 
to better, or remain stationary, or diminish in intensity, till they are merged in 
convalescence ; or may be aggravated and receive accessions — the tongue become 
dry, swollen, fissured, black, with accumulations of sordes on the teeth and lips ; 
injected eyes ; fuliginous face ; burning skin ; livid and petechial spots ; hurried, 
interrupted, imperfect respiration, accompanied by sighs and moans ; dulness at 
lower posterior part of chest on percussion ; an exceedingly rapid, feeble pulse ; 
extreme muscular prostration, but with momentary exhibitions of unnatural 
strength ; coma vigil, or great nervous agitation, simulating at times the busy 
excitement of delirium tremens ; vv'ith sometimes coolness of surface and profuse 
sweating ; terminating at a variable period, between the tenth and twentieth day, 
often earlier, rarely later, in death ; the post-mortem examination disclosing, exter- 
nally, much discoloration of depending and posterior parts — internally, the ab- 
sence rather of any considerable organic lesion, but commonly evincing more or 
less abnormal vascularity of the brain and its membranes, its substance being- 
firm and natural, the bloody points on its cut surface numerous, distinct, and 
dark — with oftentimes slight increase of serum beneath the arachnoid, and in the 
ventricles, clear or turbid ; lungs externally normal — internally normal anteriorly 
— the posterior and depending parts more dense and engorged; lining membrane 
of the bronchia reddened, stained, not usually injected ; heart soft, flabby — its 
contained blood dark, fluid, dissolved, sizy — with loose, non-coherent clots in the 
meshes of its valves ; viscera of abdomen normal, with the exception of discolor- 
ation, and sometimes simple congestion of the mucous lining of the small intes- 
tines — occasional softening of the spleen, and general fluid, sizy, disorganized 
condition of the blood throughout the body — the sum and substance of which 
symptoms, facts, and circumstances is represented under the conventional term 
of typhus." 

Interesting as are all the details embraced in the publication before us, truth- 
ful as are the author's delineations of the disease of which he treats, and deserv- 
ing as they are of an attentive study by all who would make themselves familiar 
with the etiology, pathology, morbid anatomy, and treatment of a form of fever, 
the prevalence of which, we regret to say, has of late years, increased in frequency 
and extent, in the dark, filthy, ill-ventilated, badly drained, and over-crowded 
courts, lanes, and alleys, where, in all of our larger cities, dwell the improvident, 
the destitute, and the vicious portions of the community, amid want and wretched- 
ness, and secluded, in a great measure, from the cheerful sunlight, and wholesome 
air ; still, we discover in the illustrations of Dr. Upham nothing particularly novel, 
either in relation to the causes, nature, characteristics, progress, or treatment of 
typhus fever. 

Dr. Upham assigns as the originating causes of the disease, foul and stagnant 
air, and the damp, dark, filthy, and crowded habitations of poverty, deprivation, 
and misery, he, nevertheless, assigns to it, an " eminently infectious and contagious 
character." He admits, however, that the disease should not be held as conta- 
gious in the same sense that smallpox is contagious — that is, invariably and viru- 
lently so. 

" Certainly the sphere of action is more limited — the communication of the 
poison more dependent on circumstances — and the morbific influence more within 
the control of sanitary laws and regulations, than in the usual zymotic or so-called 
contagious maladies. It may be stated as a general rule, that the contagion, to 
be effectual, must be concentrated by the crowding together of patients — or ac- 
cumulated and aggravated in ill-ventilated and pent-up rooms — or stimulated by 



194 



Bibliographical Notices. 



[Jan. 



the conjunction of other unfavourable hygienic conditions, ill-drainage, filth, 
effluvia, &c. &c. — or the recipient have been previously subjected to the predis- 
posing causes by deprivation, hardships, and want, excesses, anxiety, fear, des- 
pondency, mental and physical exhaustion or debility from any cause, till his 
system has been brought to a point below the power of resistance. 

"It follows that immunity from the reception of contagion in the exposed, and 
from an aggravation of horrors on the part of the sick, is to be gained, as far as 
possible, by a strict observance of the well-known maxims of hygiene, first aiid 
foremost among which is the possession of a stout heart and sufficiency of the 
light and air of heaven. Hence an explanation of the fact that, in the outbreak 
of the fever in 1847, when sheds and shanties open to the elements were of neces- 
sity used, in Dublin and elsewhere, both patients and attendants fared the better. 

"As is well known, the disease is often epidemic, prevailing extensively, as 
already stated, in some districts, towns, and localities, while absent in others ; 
and raging and overspreading the country in certain seasons and years. These 
last are heralded mostly by some wide-spread calamity, involving misery and suf- 
fering and general want. At such times multitudes of the most destitute flock 
to the metropolis and the other great cities of the realm, in search of food and 
employment, carrying with them a predisposition to the fever, stopping for shel- 
ter in the filthiest and most wretched abodes, sowing therein the seeds of disease, 
and, then, speedily finding their own way into hospitals to die. In the famine 
year of 1847, the fever was thus engendered and disseminated to a frightful ex- 
tent. The baleful influence extended into the following, and, conjoined with the 
cholera, even the next succeeding year. This may be called the great epidemic 
triad of modern times. It was then that the flood overflowed its natural bounds 
and poured its surplus waves of fever for the first time upon the shores of the 
New World." . D. F. C. 



Art. XX. — Catalogue of the Surgical a,nd Pathological Museum of Valen- 
tine MoTT, M. D., LL. D., Emeritus Professor of Surgery in the University 
of the City of New York, etc., and of his son, Alexander .B. Mott, M. D., 
Surgeon of St. Vincent's and the Jews' Hospital. Secat Salubritar. New 
York : 1858. 8vo. pp. 78. 

In this catalogue, over a thousand pathological specimens, the result chiefly 
of surgical operations performed by the Nestor of American surgeons, are enu- 
merated and described. It will, naturally, be most prized by students attending 
the University of the City of New York, who can find therein an explanation of 
the specimens contained in the museum to which they have access. As, how- 
ever, remarks are frequently appended to the description of the specimen, and, 
in many instances, the whole history of the case by which it was furnished, the 
catalogue possesses greater interest for the profession at large than might at 
first be supposed. Several of the specimens, also, are from cases whose history 
has been published at length, in past years, in this journal, and with which its 
readers are all more or less familiar. 

This collection is believed by Dr. M. to be the largest that any American sur- 
geon has had occasion to form, and he further states in the preface, that "more 
than fifty years of active professional life, in the most populous city in this 
country, have been spent in its accumulation." 

In order that the specimens might be arranged according to the diseases they 
represent, and thus facilitate reference, the collection is divided into forty com- 
partments. Owing, however, to the progressive manner in which it has been 
accumulated, their classification is by no means systematic. Interspersed among 
the specimens in the different compartments, are pieces of bone from Waterloo, 
Antwerp, Delphi, and the Acropolis — crania from battle-grounds, from Indian 
women, warriors, patriots, robbers, and pirates, and such little luxuries, or pue- 
rilities, of a pathological cabinet. These might have all been placed in one com- 
partment, along with some bones of an intrepid chanticleer, about whose history 



1850.] 



MoTT, Surgical and Pathologic?.! Museum. 



195 



some curiosity must naturally be felt on seeing thom in 'this collection ; they may 
be the remains of the " tutelary emblem, of glossy black plumage" once sacrificed 
by the professor to Esculapius.' 

The number of the specimens of spontaneous gangrene preserved in this pri- 
vate museum is quite remarkable ; it is no less than thirteen. One of these is of 
the upper extremity, where its occurrence is exceedingly rare, so much so that 
the account furnished in the catalogue will be given here. 

"No. 810. Spontaneous mortification of the right arm of a lady in Brooklyn. 

" She was about 35 years old, the mother of several children ; rather delicate ; 
no known cause for it. The first thing noticed was unusual coldness of the hand. 
The mortification gradually advanced to about the middle of the arm, where it 
stopped, and in great measure separated from the living, healthy surface above. 
At her urgent solicitation, but without my recommendation, I amputated the 
arm, as the fetor from it was intolerable to her. The brachial artery was solid, 
and did not require a ligature. Several smaller branches were tied. 

" Four or five days after, upon opening the stump, mortification was apparent 
in it. She died in a few days, from exhaustion" — p. 14. 

At page 72, Dr. Mott says : I have operated successfully in several cases of 
spontaneous mortification, but have also failed. My experience is in favour of 
amputation through the thigh, even though the toes only should be involved in 
the mortification. The greater the distance from the seat of the disease, the 
more probability is there of the arteries being in a normal state." 

From these thirteen cases, it is also seen that Dr. Mott performs amputation 
while the mortification is advancing up the limb. This proceeding is condemned 
by most surgeons; many of whom reject it in almost all cases, even when the 
gangrene has ceased to progress. Some most trustworthy statistics show, that, 
of eight cases of spontaneous gangrene in which amputation was performed, five 
died and three recovered ; while of eleven cases left to themselves, only one died, 
and ten recovered. 

In some remarks made upon a case oi fungus licematodes of the right eyeball 
(p. 39), it is advised, in addition to extirpating the eye, to tie the common carotid 
artery of the affected side, as the plan " best calculated to postpone, and some- 
times prevent, the return of the disease." In this case, no return had taken 
place when the patient was last seen, which was two years after the operation. 
This patient, it should be added, was a female child about seven years of age. 

Specimen No. 426 is a very curious one — absence of the epiglottis. It was dis- 
covered after death. " The absence of the cartilage is complete, and, as there 
is no cicatrix visible, it is probable that the defect is congenital. There was no 
suspicion of its existence before death" — p. 26. 

Nos. 810 and 478 are specimens of scirrhus of the male breast. " The tumour 
was characterized by extreme hardness, lancinating pains, and great retraction 
and puckering of the nipple — the features of true scirrhus !" In neither was 
there any return of the disease. A case of encephaloid disease of the same 
organ is also in the collection, No. 755. "The mass of disease contained several 
cysts, which, when cut into, discharged an inky fluid, leaving a dark stain on the 
linen — melanotic infiltration." In this, likewise, there was no return. 

At page 8 we find : " No. 741. Testicle (healthy). Eemoved from Dr. L. L., 
at his own request, as a cure for onanism. After recovery from the operation, 
he resumed the habit, but not to the same extent as before." 

We hope, for the credit of American surgery, that this may ever be an unique 
specimen. 

At page 34 is recorded a case of malignant sarcoma, which shows strikingly 
the obstinacy with which such affections return. The patient was a man of ex- 
cellent constitution and general health. The disease was situated in the side. 
Most of the operations were very extensive and extremely painful. At no time, 
in any of them, was there the least morbid portion left, and the wound invariably 
healed in the most kind and rapid manner. This is the record of the different 
operations : — 

' See Travels in Europe and the East, by Valentine Mott, M. D. New York, 
1842, p. 297. 



196 Bibliographical Notices. [Jan. 



In Ireland . . 



June, 1832, 
May, 1837. 
August, 1840. 



By Dr. Horplilin. 

Dr. Herbert Orphen, 



[ April, 1841. 
f June, 1843. " Dr. Mott. 
June, 1847. 
May, 1851. 
Jan. 7, 1853. 
August, 1853. 
In New York . . . Jan. 7, 1854. 

May 26, 1854. 
Oct. 25, 1854. 
Jan. 30, 1855. " 
Mar. 9, 1855. " 
[ June, 1855. " 
The patient died of the disease, in the fall of 1855. 



Dr. A. B. Mott. 
By Dr. A. B. Mott. 



W. F. A. 



Aet. XXI. — Description of a Neiu Midwifery Forceps, having a Sliding Pivot 
to prevent Compression of the Foetcd Head ; ivith Cases. By Geokge T. 
Elliott, M, D., Physician to Belle vue Hospital, the Nursery and Child's Hos- 
pital, and the Lying-in Hospital, etc. etc. 8vo. pp. 24. 

"There is no end," said the wise king, "to making of many books," and, with 
equal propriety, it may be said, there is no end to the invention of new obstet- 
rical forceps. Nearly every obstetrician believes himself competent to improve 
the instrument, by giving to it a new or additional curvature, by modifying 
its form, by changing the shape or breadth of its blades, or by adding to 
it some contrivance having for its object to facilitate its introduction and 
adjustment, or to prevent any injury being inflicted by it upon the head of 
the foetus or the maternal organs. Whether all these are to be considered 
as improvements, it would be very difficult positively to determine; inasmuch 
as there is, we suspect, no one who has ascertained, from actual experience, 
the advantages and disadvantages of the several forceps in use, or which have, 
from time to time, been recommended as possessing excellencies in which 
all others are deficient. Each practitioner has a favourite instrument of his 
own, which, perhaps, is generally condemned by others, and this, perhaps, less 
from any positive evidence they may possess of its imperfections than from the 
fact that, being accustomed to the use of a certain form of instrument, they have 
acquired a facility in its application, and thus become so far satisfied with it, as 
to render them disinclined to make trial of any other. 

That, from the results of increased experience, no very material imiprovements 
in the form and general construction of obstetrical forceps have been or can still 
be devised, we have no right to aflirm. We believe they have been and that they 
may still further be improved. 

In the pamphlet before us, we have the description of a new obstetrical for- 
ceps, the peculiarity of which consists in the insertion in the handles of " a slid- 
ing pivot" (pin?), by which the blades are prevented from being approximated 
more nearly than is necessary to permit them to simply grasp and retain hold of 
the foetal head without compressing it. 

According to Dr. Elliott, " the most that can be expected of an instrument is, 
that it successfully meets very numerous indications." He believes — 

"1. That the principal use of the forceps, in the immense majority of cases, 
is that of a tractor alone ; and that compression is always in some degree inju- 
rious, and to be avoided if possible. 

" 2. That this traction can be applied, and should be applied, by competent 
men, in well selected cases, even though the head so float above the brim as to 
be only capable of being steadied by the hand, introduced above the pelvic brim ; 



1859.] Elliott, Description of a JN'ew Midwifery Forceps. 191 



and that thus the class of forceps known as short forceps w^ould not, in these 
cases, meet the full requirements of the art. 

" 3. That this traction can be applied, and should be applied, by competent 
men, in well selected cases, through an os uteri, as yet barely dilated suffi- 
ciently to admit the blades separately, and that delivery may subsequently be 
effected by dilating-, or lacerating- or incising the os and cervix uteri ; and that, 
in many of these cases, the neg-lect of this procedure entails loss of foetal life, 
demands the perforator, or perils the mother's life by delay, based on ignorance 
of the full capabilities of the instrument. 

"4. I believe in the existence of a large class of cases, in which a light and 
slender forceps can simplify delivery by altering the position of the head — a pro- 
cedure inoperative and injurious, when performed with instruments of large 
pelvic curve — while its neglect frequently demands the perforator, or makes the 
difference between a safe operation, or one of the greatest risk, to one or both 
of the lives at stake. 

" 5. That a forceps capable of fulfilling all these requisitions must, of neces- 
sity, be vrell adapted to those simpler cases, to which some men would limit their 
use, rendering them, in the words of Dewees, ' scarcely subservient to the art.' 




Whole length, of forceps 



A to B 
G " D 



E ' 
G ' 
I ' 
K ' 
L ' 
N ' 
P ' 
N. B. 



inches 



. 15^ inches, 
face of forceps, 
back " 



E to S . . . 

T " IT . . . 

V " \V . . 

X " Y . . 

Z " A.' . . 

B " C. . . 
Length of pin 



f inches, centre of fenestra. 



1^ 



Thickness of blade R S 
thinner at the end. 



of an inch, a little 



F 
H 
J 
L 



-B'. This hole is sufiBciently deep and wide to receive the entire pivot when it is not needed. 
C is a little deeper than tho'^e a'bove, so that the distance between the handles may be nicely 
graduated by the pivot. 

D' to E'. These overhanging projections serve to prevent any risk from slipping of the lock when 
the handles are widely separated. 



198 



Bibliographical Notices. 



[Jan. 



" Thus tlie forceps now presented is made as light as is consistent with strength, 
with its diameters as small as the indications given above would seem to warrant; 
while the introduction of the pivot allows handles long enough to be grasped by 
both of the operator's hands, without fearing risk to the child from pressure, 
either when the foetal head is large, or in those operations where it is utterly im- 
possible now, and must ever be utterly impossible, to seize the head in any other 
way than by its oblique diameters." D. F. 0. 



Art. XXII. — An Essay on the Pathology and Tiierapeutics of Scarlet Fever. 
By Caspar Morris, M.D., Fellow of the College of Physicians of Philadelphia, 
etc. etc. etc. 8vo. pp. 192. Philadelphia: Lindsay & Blakiston, 1858. 

A MONOGRAPH on scarlet fever, embracing the result of more than thirty years' 
observation of the disease by the author, in various public institutions as well 
as in private practice, cannot but be hailed by every practitioner as an acceptable 
addition to his means of instruction in respect to the nature, phenomena, and 
treatment of one of the most formidable of the diseases he may be called upon 
to treat. A disease which in its more severe forms has, heretofore, almost invari- 
ably marched on, with greater or less celerity, to a fatal issue, in despite of the 
most skilfully directed efforts of the physician to stay its destructive course, and 
which, even in cases where the patient struggles through the attack, and is per- 
mitted "to linger into life," leaves behind it chronic lesions of important organs, 
"equally, perhaps more, to be dreaded than the primary disease." 

The essay of Dr. Morris claims to be such a monograph. It is an enlarged 
and amended edition of an essay published by him some years ago, and which 
was most favourably spoken of by such as had occasion to consult its pages. 
The work, in its present form, though somewhat deficient in method, and in many 
parts unnecessarily diffuse, presents a very fair, accurate, and satisfactory expo- 
sition of the actual state of medical opinion in respect to the pathology and 
therapeutical management of scarlet fever, in the various degrees of intensity, 
and with the different modifications and complications under which it presents 
itself, in the same or in different epidemic visitations. 

We cannot say that we find in the work of Br. Morris, any more accurate de- 
lineation of the disease ; any clearer views of its nature, nor any more judicious 
and successful plan of treatment, than is contained in any of our leading sys- 
tematic treatises on the practice of medicine, general or special. Still the publi- 
cation of the essay is to be approved, inasmuch as it furnishes us with a statement 
of views in respect to the nature and management of a most important malady, 
the accuracy of which the author believes to be confirmed by a long and exten- 
sive experience. The comparison of views thus tested, with those derived by 
ourselves from our own field of observation, is an important means of enlarging 
and perfecting our acquaintance with disease, and perfecting our skill in its suc- 
cessful control. 

Our own experience differs from that of the author in some few particulars. 
Thus, we have seen no facts to convince us of the contagiousness of scarlet fever ; 
nor can we concede to the evidence adduced by the author and by others, so con- 
clusive a character as he claims for it. It would but illy stand the test of a rigid 
logical scrutiny. We cannot conceive of a disease so eminently contagious as to 
be contracted, like, we are told, scarlatina may be, by simply looking upon an 
entirely new garment that had been sent, some distance, from a house in which 
the disease was prevailing, occurring as an epidemic, within such narrow limits 
as a single block of houses, while all the neighbouring square remained free from 
it, or, as we have more than once known to be the case, visiting every house on 
one side of a narrow street, while on the opposite side, not a single case occurred. 

In the management of scarlet fever Dr. Morris advocates a mild and soothing 
or a sustaining tonic, and stimulating treatment ; in this he is borne out by some 
of the best authorities in the profession, and in the mild, simple form of the dis- 



1859.] 



Waiters, An Essay on Inflammation. 



199 



ease, as well as in tlie low and malignant type, under which, in some of the epi- 
demical visitations it occurs, the treatment recommended by Dr. Morris is con- 
fessedly the only one calculated to conduct it to a favourable issue. 

That cases of scarlatina do, nevertheless, occur, in the early stage of which a 
judicious resort to direct depletion by the lancet or leeches, will be found de- 
cidedly beneficial, we have been forcibly taught by experience. We are convinced 
that, in the sthenic, or open inflammatory form under which the disease not un- 
frequently presents itself, the abstraction of blood, at the proper period, and to 
a proper extent, is a measure adapted not only to conduct it more certainly to a 
favourable close, but to prevent tlie occurrence of most of the serious sequelse 
incident to the disease, more especially when it is neglected or mismanaged. 

D. F. C. 



Art. XXIII. — An Essay on Inflammation : the tenth of a Series of Articles 
published in the St. Louis Medical Journal, on Lifei" By J. H. Watters, 
M. D., Professor of Physiology in the St. Louis Medical College. 8vo. pp. 32. 
St. Louis, 1858. 

That vital phenomena are never exhibited excepting in organized matter, and 
every vital action, process, or movement is attended with a metamorphosis, dis- 
integration, or decay of the tissue in which it occurs, are propositions the truth 
of which is admitted we believe by all physiologists. In an essay published in 
1851, and noticed in a former number of this journal (for July, 1852), Dr. Wat- 
ters attempted to show that organization is a form impressed upon matter by the 
Creator, in order to convert matter into a machine, by means of which advantage 
is taken of the laws with which he has endowed it, to produce certain results — 
vital actions — vital phenomena ; and that these actions or phenomena result 
necessarily from the peculiar form or arrangement of the matter constituting the 
organism, when this is placed under the proper conditions, and that all the pro- 
cesses, actions, or functions of a living organism are the effects of forces which 
are evolved in its decomposition or decay. 

These views, first publicly announced hj Dr. Watters in 1851, have since then 
been further elucidated and enforced by him, in a series of articles that have ap- 
peared from time to time in the St. Louis Mediccd Journal. 

In his first essay, Dr. Watters endeavoured to deduce confirmatory evidence 
of the truth of his theory of life by applying it to an elucidation of the pheno- 
mena of inflammation ; the explanation of the pathology of inflammation there 
laid down is, in its general outlines, and even in some of its details, proposed by 
Dr. Hinton, in an article published by him in the number of the British and 
Foreign Medico-Chirurgiccd Revieio for July, 1858, as one which is both clear 
and satisfactory, and by which the facts connected with the phenomena and 
course of inflammation are better co-ordinated than has been done by any other 
theory of the disease. The A'iews advanced in the article of Dr. Hinton to which 
we refer, he assumes as original with himself ; not the slightest reference being- 
made to the previous publication of Dr. Watters. We would not be understood 
as accusing Dr. Hinton of plagiarism. Notwithstanding the very remarkable 
similarity between the theory of inflammation as set forth by him in the paper 
referred to and that publicly announced by Dr. Watters seven years previously, 
it is very possible that it was developed in the mind of Dr. Hinton without any 
knowledge of the essay of the former gentleman, and by a course of reasoning- 
commencing from a very different and dissimilar starting point. And this fact 
of the almost entire identity of the general idea of life, or vital action, upon 
which is based the pathology of inflammation advanced by both these gentlemen, 
and arrived at by each entirely independent of any knowledge of the other's 
labours, may be assumed, we think, as a pretty certain evidence of the value of 
that idea, and of its foundation in truth. But, whatever may be the estimate we 
may be inclined to place upon the doctrine of vitality here referred to, the claim 



200 



Bibliographical Notices. 



to priority in its announcement and elucidation must be decided in favour of Dr. 
Watters. 

"With Dr. Hinton," Dr. W. remarks, "the position that the increased action 
of inflammation is the effect of increased decay, is an induction ; with me, the 
position that the phenomena of inflammation depend upon a disproportion be- 
tween decay and nutrition, is a deduction from the general proposition that 
decay is the vital motor, and this from the more general one that Form and Mo- 
tion are the primary conditions of every mode of motion in physical nature. 
Hence, the question considered by me is, upon the supposition that decay is the 
vital motor, Can the phenomena of inflammation be explained ? If so, then this 
deduction is a strong verification of the general proposition. If the phenomena 
of inflammation justify the induction of Dr. Hinton, how much more do they 
justify this deduction ! For a class of facts which alone might not be sufficient 
for an induction, might be quite sufficient for a deduction, to confirm a position 
already arrived at by induction from other facts. But Dr. Hinton thinks the 
facts of inflammation are sufficient for an induction ; in fact, by induction he 
arrives at the same theory of inflammation which I did by deduction. What 
greater verification than this could there be ? And he presents the same class 
of arguments, too, as sufiicient for the induction, which I presented in my thesis 
to establish only a deduction. This is really a greater verification than I ex- 
pected so soon." 

We do not intend to enter into an examination of the actual force and validity 
of the arguments presented by our author in support of the doctrine of life and 
vital action advanced by him ; nor shall we attempt any comparison between 
that doctrine and the generally received proposition that living organized mat- 
ter is endowed with a certain property or force, upon the presence of which all 
its vital acts and phenomena, abnormal as well as normal, are dependent, with 
the view to test which is the best adapted to explain the functions of the 
organism in their healthy state and the phenomena of disease. 

Our general opinion of the views advanced by Dr. Watters, and the manner in 
which his exposition and defence of them has been executed, was expressed on 
a former occasion when his original essay was under consideration. Both hypo- 
theses, that of a specific independent vital principle connected with organized 
matter, and that which views vital action as the result simply of the disintegra- 
tion or destruction of organized tissues, are unquestionably attended with serious 
difficulties as exponents of the vital movements of the human organism in its 
physiological or pathological conditions. Should, what many of those whose 
opinions on questions of physiology are received as of great weight assert, be 
true, that, namely, the disintegration or destruction of tissue is an event always 
consequent upon and never preceding vital action, we would then be scarcely 
warranted in setting up the disintegration or decay as the motor of vital action. 
While, on the one hand, the mere precedence of decay or destruction of tissue to 
any given vital act would by no means be sufficient of itself to prove that the 
decay or destruction is the cause or motor of such act, on the other hand, the 
fact of the change or decay of tissue being invariably sequent to vital action, is 
almost conclusive evidence that it cannot be received as the cause or motor of 
the latter. We admit that, in investigating this question, we must be cautious 
not to be led astray by confounding the visible resulting consequences of disin- 
tegration or decay of tissue with the actual process of decay itself. 

In the essay before us. Dr. Watters has endeavoured to remove some of the 
presumptions that may be entertained against the truth of his theory of life, 
while he presents some additional evidence in proof of the correctness of the 
views of inflammation deduced by him from it. 

These views, arrived at as they have been, by two shrewd minds, without any 
knowledge of each other's labours, cannot but be worthy of the consideration of 
every one in the pursuit of physiological and pathological truth. D. F. C. 



1859.] Thompson, Stricture of Urethra and Urinary Fistulae. 201 



Akt. XXIY. — The Pathology and Treatment of Stricture of the Urethra, and 
Urinary Fislu,lai. By Henry Thompson, F. R. C. S., M. B., Lend., &c. Second 
edition, much enlarged and revised. London: John Churchill, 1858. Octavo, 
pp. 426. 

The first edition of this work, published in 1854, was reviewed at length in this 
Journal (July, 1855). It remains for us, therefore, but to point out the changes 
which have been made in this second edition. 

The author has introduced in the body of the work much of what was formerly 
contained in the appendix ; sometimes in the form of foot-notes, and, when it is 
illustrative cases, at the close of an appropriate chapter. A slight alteration 
has been made in the order of the chapters, the one treating of urinary abscess 
and fistulge now preceding the one upon retention of urine. The historical por- 
tion of the subject has been everywhere improved; old works are referred to for 
the first time, and mention is made of several works of merit — as those of M. 
Guerin and Mr. Henry Smith — that have recently appeared; enlarged experience 
has also enabled the author to furnish new cases in illustration of his teaching. 
An alteration we regretted to encounter is that of indicating the subject of the 
paragraphs by printing it in large type at the commencement, in place of small 
type at the side on the margin of the leaf For reference, the plan adopted in 
the former edition is decidedly preferable. A few new wood-cuts have also been 
introduced. These are the changes made in the general arrangement of the work. 
We shall proceed now to notice those made in its several chapters. 

On the subject of anatomy, the presence of the rugge so numerous in the bulb- 
ous and membranous portions of the urethral canal is said to be owing to the 
existence of numerous long and slender bands of fibrous tissue lying immediately 
beneath the mucous membrane. The venous circulation in the urethra is de- 
scribed for the first time ; and in connection with that much vexed subject, the 
muscle of Wilson, there is an alteration in the text, which reads ''muscular fibres 
descending from the pubic symphysis and adjacent bone to the membranous part 
of the urethra," instead of "to the side of the prostate, and towards the urethra, 
just anterior to it, the latter especially not being constant in quantity in diSerent 
bodies, in some being little if at all developed." The observations of Professor 
Ellis [Med.-Ghir. Trans., vol. xxxix.), to which reference was made, in a notice 
made of Mr. Thompson's work on the prostate gland, in the number of this Jour- 
nal for April last, have also been made use of to more fully complete the anato- 
mical descriptions. 

In treating of the classification and pathology of stricture, attention is called 
to the fact that, in laying open the urethra after death, transverse bands, encir- 
cling the urethra and narrowing it, are divided so that the stricture is often less 
obvious than was anticipated. According to their anatomical characters after 
death, organic strictures are classified as linear, annular, indurated annular, and 
irregular or tortuous strictures. These terms explain themselves, the distinction 
between linear and annular being understood to be the greater breadth of the 
constricting band in the latter form. Mr. Thompson is less inclined than before 
to believe in the existence of stricture from a deposit of false membrane upon the 
urethra, and cites with satisfaction the corroborative opinion of M. Gu6rin on 
this point in pathology. The most frequent seat of stricture is no longer believed 
by him to be at the junction of the spongy and the membranous portions of the 
urethra, but the portion comprised in the inch anterior to the junction — that is, 
the posterior or bulbous part of the spongy portion. We also notice (p. 61) that 
Mr. Thompson has encountered a second impermeable stricture (properly so 
called). 

To the account given of the symptoms and pathological effects of organic 
stricture not much has been added. Retention of urine is noticed as being in 
some cases the most prominent symptom throughout; and also, in others, a tend- 
ency to rapid recontraction after dilatation, giving rise to the form called by Mr. 
Syme "the resilient stricture." According to their prominent pathological tend- 



202 



Bibliographical Notices. 



[Jan. 



ency, organic strictures are classified as simple, sensitive or irritable, and con- 
tractile or recurring (resilient of Syme). 

Nothing has been changed in the chapters treating of the causes of organic 
and permanent stricture, and of the pathology of strictures which are only of 
transient duration. 

The chapter upon the diagnosis and treatment of stricture of the urethra, and 
the employment of dilatation, has been much improved. Mr. Thompson recom- 
mends now, in order to explore the urethra with a sound, that the patient be 
placed in a recumbent position, and gives minute directions for the guidance of 
the practitioner. He declares, also, that he can speak highly of the utility of 
bulbous sounds in making this exploration in stricture, as enabling the surgeon 
to ascertain with accuracy the locality and extent of the contraction. In passing 
a sound for the purpose of dilating a stricture, attention is called to the unneces- 
sary length of time the instrument is often allowed to remain in the bladder ; in 
most cases Mr. Thompson believes that as much benefit will be obtained by 
removing it at once as by permitting it to remain. "We find that he has changed 
his mind in regard to using instruments to overdistend the canal chiefly at the 
contracted part, and now states it to be undoubtedly sometimes advantageous. 
In regard to instructing patients to pass the catheter, in place of "some few" we 
now read that "a considerable number" should be thus instructed. The steel 
conical sound is still a favourite instrument with Mr. Thompson, his armamenta- 
rium consisting now of six, in place of three, which formerly constituted for him 
an efficient set. When a very small instrument must be used, of course very 
little oil can be made to adhere to it ; and just as the instrument diminishes in 
size, so does the presence of the oil become increasingly necessary. The simple 
method of applying the oil to the urethra itself, and very freely, rather than to 
the instrument, is recommended; by means of a common glass syringe, about 
half an ounce of pure olive-oil is injected slowly into the urethra. Mr. Thompson 
states that he has obtained considerable advantage fromi the use of oil in this 
manner. The necessity that exists of using great care in carrying the point of 
the instrument through that part of the canal which lies behmd it, on account of 
the irregular character of the urethral walls, not uncommon in old and tight 
strictures, is insisted upon. In cases where it is found necessary to tie a catheter 
in the bladder, it is recommended to adopt the plan of fitting to the orifice of the 
catheter a bent tube or siphon containing a stopcock. This prevents completely 
the flow of urine downwards along the outside of the shaft of the instrument when 
the patient occupies the recumbent position. "Excoriation of the skin is thus 
prevented, and that wetting of the linen and bedclothes, which is exceedingly 
disagreeable and troublesome, indeed mischievous, when the catheter has to be 
retained for a considerable period." The part of this chapter occupied with the 
constitutional treatment of patients with stricture has been greatly improved, 
and we should also notice that the rationale of the action of dilatation is dis- 
cussed therein for the first time. 

The chapter on the employment of chemical agents in the treatment of stric- 
ture has been very little altered. In the old edition he stated that " some of the 
modern French surgeons use nitrate of silver largely," while in the present one 
he says, more correctly, that "it is only fair to our French brethren to state that 
the use of caustics is now almost universally reprobated by them," a tbrm of 
expression that conveys a more correct idea of the French practice. We have 
noticed throughout the work, in many places, evidences of further acquaintance- 
ship with French writings and French practice than Mr. Thompson gave evidence 
of possessing in the first edition of his work. It is this, probably, that has induced 
him to regard more favourably the treatment of stricture by internal incision. 
After a good deal of personal attention to the subject, and some experience of 
the methods adopted, he expresses himself as satisfied that internal urethrotomy 
offers a very successful means of dealing with certain intractable examples of the 
complaint. The proceeding adopted by Civiale appears to him to be one of the 
best. The following conclusions, which form a summary of the chapter upon 
internal urethrotomy, will show the change in his views : — 

''Internal urethrotomy is indicated in almost all strictures affecting the exter- 
nal meatus of the urethra ; and in many cases of stricture situated about the 



1S59.] 



Garner, Eutherapeia. 



203 



middle of the spongy portion, for which dilatation, fairly tried, has proved unsuc- 
cessful. 

''It is useful, also, in some few cases of stricture situated at the bulbous por- 
tion, which are not relievable by dilatation ; a single incision, which is not deep, 
being- free from danger, and frequently rendering the stricture perfectly amenable 
to dilatation afterwards. 

"Lastly, it is so in those rare cases in which the urethra is narrowed and indu- 
rated at many points, or throughout a great portion of its course, dilatation 
having been found inefficient." 

The historical portion of the chapter upon external incisions has been much 
enlarged. AVe notice that to Jean Luis Petit is accorded the credit of having 
first performed a cutting operation for the cure of the stricture, and not for the 
mere relief of a complication. This was first shown, if our memory serves us, 
in a paper on Syme's operation, in the Archives Generales, by M. FoUin. Mr. 
Thompson has made it his business to w^rite to every surgeon who has performed 
the operation, and has collected a list of 219 cases by thirty operators. In this 
list "the total number of deaths occurring within two or three months after the 
operation, whether due to it or not, is fifteen. One, certainly — two, I think — 
fairly were not chargeable to it ; leaving say fourteen, or slightly over six per cent. 
But four others were the sulijects of advanced disease of the kidneys, and there- 
fore ought never to have undergone the operation, and with our present experience 
would not have been submitted to it." The mode of performing the operation is 
much more carefully described in this new edition. 

In the treatment of retention of urine depending on stricture, Mr. Thompson 
in his first edition recommended the employment of chloroform. In this one he 
speaks of its benefit with still greater confidence and satisfaction. Sometimes, 
after the ablest hands have failed to pass an instrument, the urine has been spon- 
taneously expelled when the patient was fully subject to its influence. 

The chapter upon urinary abscess and fistulte has been more improved than any 
in the work. A very proper division of fistulas is made into simple, indurated, 
and fistulas vriih. loss of substance. The cure of the last form of fistulas — in other 
words, the subject of urethroplasty — entirely neglected in the first edition, is now 
treated of at considerable length.- 

The chapter upon stricture of the female urethra is the same. 

We must therefore look upon the changes made by Mr. Thompson in this 
work — the best of all that treat of stricture — as enhancing considerably its value. 

In his preface to this second edition Mr. Thompson states that the most flatter- 
ing appreciation of his labours was that which appeared in the appropriation of 
thirty pages of the second chapter by a foreign surgeon, first pointed out in a 
review of the Treatise on Stricture, by Henry Smith, in the number of this 
Journal for April last. He adds "that it would be impossible for the author to 
omit this opportunity of presenting his sincere and cordial thanks to the press of 
this country, of France, and of America (in the latter the fraud was first disco- 
vered and exposed), for the prompt and complete manner in which it hastened to 
lay bare and publish to the world the fraud in question." It is somewhat remark- 
able that this should be the first public acknowledgment made in England of the 
tact that this remarkable plagiarism was first pointed out in this country. British 
reviewers have tried to make it appear that the discovery of this plagiarism was 
the result of the very extensive acquaintance of English surgeons with continental 
medical Literature. W, F. A. 



Art. XXY. — Euiherapeia ; or, an Examination of the Principles of Medical 
Science, with Researches in the Nervous System. By Egbert Garner. Sur- 
geon to the North Staffordshire Infirmary, etc., late President of the North 
Staifordshire Medical Society, author of Papers in the Linnasan and Zoological 
Transactions, and of the Natural History of StaS'ord. London : John Churchill. 

It would seem from the appendages to the author's name on the title page, 
and from one of the chapters in his book, that he has been devoted to a consider- 



204 



Bibliographical Notices. 



[Jan. 



able extent to researches in comparative anatomy and natural history ; and^we 
infer from what is said in his preface that he, in common with many others in our 
profession, has had his practice lessened on account of these researches, although 
they are certainly tributary to a knowledge of practical medicine, and the phy- 
sician who pursues them in his leisure hours adds to his resources in the investi- 
gation and treatment of disease. It seems that in England as well as this country 
it is almost always injurious to a physician's standing with the public as a prac- 
titioner, to be known to be engaged in any investigations which have not the 
most palpable and direct bearing upon his practice. Those generally have the 
largest practice who are careful to be known only as practitioners of medicine — 
the idea of the public being that they are so much engrossed in their practice, 
that they have neither the time nor the inclination to attend to anything else. In 
many communities such an impression is so essential to success, that it is the 
general aim of the young physicians to produce it in regard to themselves, before 
they really have business enough to occupy more than a very small proportion of 
their time. And we have no doubt that it is good policy ordinarily for one who 
wishes to push his researches into studies that have not a palpable bearing on the 
treatment of disease, to conceal the fact that he does so from the great body of his 
employers. If he does not, they will get the impression that he has so little prac- 
tice that he has time to attend to other matters, and will think that he is so much 
interested in them that he will not take a proper interest in his patients. The 
truth is, that the investigations referred to really make one a better practitioner, 
not only by adding to his resources, but also by giving him an agreeable relaxa- 
tion from the toils of practice, thus adding both to the buoyancy and the vigour 
of his intellect. The physician who confines himself wholly to the drudgery of 
practice, going through the same routine day after day, both narrows and be- 
littles his mental powers. And he who pretends to do this as a matter of policy, 
and going about with bustling air, really spends little of thought upon anything, 
thoug-h the world may be cheated into the opinion that he is very skilful, is really 
but little above the veriest quack that he affects to look upon with such holy 
horror. 

But to the book that we have in hand. It has a singular title, and is somewhat 
singular in its character. The chief object of the author, as he states it in his 
preface, is "to demonstrate that considerable reliance may be placed upon the 
present theories and practice of medicine, bearing in mind, however, that more 
light remains to be shed on very many medical subjects, and that all human 
opinions and doctrines are, liable to error." • In order to do this, he attempts to 
give a picture of the state of medicine at the present time. 

While there are many good things in the book, regarding the book as a whole 
it is a failure. All the parts of it do not contribute to the end aimed at. The 
best chapter in the book has the least practical bearing upon the object for which 
the author writes. In this chapter he gives us an admirable view of what is 
known of the comparative anatomy and physiology of the nervous system, and we 
have no doubt that he could write an extended treatise on this subject which 
would be of great value. It is a subject on which he is evidently at home. The 
next chapter also, which is on "Physiological and Pathological Chemistry, or 
Chemistry in connection with the Functions, Changes, and Diseases of our Bodies," 
is marked by comprehensive views and an intimate knowledge of all the minutiae 
of the subject. 

In the next two chapters he undertakes to give a sort of running account of 
what we know at the present time of the nature and treatment of diseases. He 
goes over too much ground, in too general a way, to give the reader much de- 
finite information. The style in which he does it is dashing and off hand, and it 
would seem that sometimes he hardly is aware of exactly what he is saying. It 
is on this supposition only that we can account for some passages that occur. 
For example, he says, "Asthma appears to be a purely spasmodic disease, attend- 
ant on some peculiar conformation of the chest, or lungs, or breast." Now he 
cannot mean that it is either universally or generally attendant upon such con- 
formation, and yet he says so in effect. In noticing delirium tremens, he speaks 
of there being an alcoholic poison in the blood, and of ridding the system of it by 
brisk purgatives as one great object in the treatment of it. 



1859.] 



GoDARD, Monorcliidie et la Cryptorcliidie. 



2C5 



Chapter 6, On Medicinal Agents and their Classification," is a short one, 
and contains nothing worthy of special notice. 

Chapter 7, is " On the Divine Dispensation in Disease." There is much that is 
valuable and interesting in it, but we do not see that it is exactly pertinent to 
the avowed object of the book. Indeed, there is much in the volume that gives 
it, as we may say, a patchwork character. 

We are much surprised at one opinion which the author expresses. He says 
of cancer, encephaloid tubercle, and melanosis, that "it is questionable whether 
the plan of treatment pursued by the quack with these latter is not sometimes the 
most efficacious, destroying their vitality by powerful escharotics, and causing 
them to drop out, rather than our method of extirpation by the knife." 

In the last chapter, which is on pseudo-medical science, some effectual blows 
are dealt upon phrenology, mesmerism, hydropathy, and homoeopathy. We will 
give one or two specimens of his mode of treating the last named delusion : — 

"To show nature's want of curative power, Hahnemann, most unhappily for 
himself, points out that ' it cannot bring together the gaping lips of a wound, and 
by their union effect a cure ; it knows not how to straighten and adjust the broken 
ends of a bone ; it cannot put a ligature on a wounded artery, but in its energy it ' 
causes the patient to bleed to death.' No, nor can it convey our meat and drink 
to our lips without our own mechanical effort. In the above instances, we see 
manifested, in a manner that in all ages has obtained the admiration of mankind, 
the consummate skill of nature. No, Hahnemann, we cannot give up this prin- 
ciple for your dogma; and you above all others ought not to require it, for with- 
out the vis medicatrix naturae, what would your treatment be ?" 

It is thus that he brings the experience of the profession to bear as a full bat- 
tery upon the exclusiveness of Hahnemannism. "We do not think it 'contrary 
to nature' to seek to cure disease by an open combat with it, by what Hahne- 
mann terms antagonistic measures ; so far holding the ancient maxim, contraria 
contrariorum sunt remecUa. We apply cold to the hot head or skin in a frenzy 
or fever; a warm bath when the perspiration has been suppressed; we bleed in 
plethora or inflammation, and thus destroy the ipabulum of disease, or in hemor- 
rhage, to take off, by mechanical means, the vis d tergo ; we give an alkali by a 
chemical law to neutralize the acid which may be proved to be present ; purga- 
tives in constipations ; astringents in hemorrhage or diarrhoea ; kousso in tape- 
worm ; all wrong, according to Hahnemann. We have found that we can citb, 
tuth et jucunde relieve a colic by a carminative; a syncope by ammonia; a spasm 
by an opiate ; or a gastralgia by a dose of brandy ; and we adopt such methods, 
though they are deprecated by Hahnemann, as merely palliatives. In fact, we 
adhere to no dogma, neither the one given above, nor the opposite one of the 
homoeopaths, viz., 'like cures like;' we avail ourselves of various laws and prin- 
ciples — our remedies may be vital, chemical, or mechanical; specific, derivative, 
or counter-irritant; diverse enough, at any rate, to prove that we are less system- 
ists than the homoeopaths themselves; a point on which they attack us." 

W. H. 



Art. XXYI. — Etudes sur la Monorcliidie et la Cryptorchidie chez VHomme. 
Par M. Ernest Godard, Interne des H6pitaux de Paris, Membre de la Societe 
de Biologic et de la Societe Anatomique. Extrait des Memoires de la Society 
de Biologic, annee 1856. Paris, 1857. Octavo, pp. 164. 

In a recent number of this Journal (that for April, 1858), the last volume of 
the published minutes and memoirs of the Biological Society of Paris was briefly 
noticed. Attention was then called particularly to the great variety of subjects, 
in the study of which the members of that active society were engaged. It is an 
error, but a very common one, so much so that we feel called upon to refer to it, 
to suppose that the field allotted to the biologist in the domain of science is one 
of narrow limits. This error arises from a prevailing notion that when there is 
no longer life in an object, it is no longer an object for study to the biologist ; 
and again, that any departure from the normal condition of things places a living 
No. LXXIIL— Jan. 1859. 14 



206 



BiBLIOGRArHICAL NOTICES. 



[Jan. 



organized being beyond his legitimate field of research. This is not so, however ; 
biology, meaning life word, everything connected with vital phenomena must be 
the object of the biologist's research. Biology does not mean simply the science 
of live animals, but the science of all organized beings in their two conditions, 
statical and dynamical, as fitted to act and as acting. Under the one condition, 
it comprises their organization or their anatomy, both normal and pathological, 
and the laws of their arrangement in natural groups, or biotaxy. Under the 
■other condition, it comprises the influence of the medium in which the organized 
heing is placed, or, in other words, the influence of exterior agents ; and physi- 
ology, or the study of the functions of the organs. 

The memoir which we are now called upon to notice has been extracted from 
the memoirs of the Biological Society of Paris for 1856, and published thus in a 
separate form. It is a work of very considerable importance, and contains in- 
formation of value to the physician, in the several points of view of anatomy, of 
physiology, of pathology'', and of legal jurisprudence. 

The testicles, developed in the abdomen, descend gradually towards the scro- 
tum, into which they fall at the ninth month of intra-uterine life. They may, 
however, be arrested in their course, and a temporary or a permanent anomaly 
be constituted, which has been called monorchidia, single-testicle, or cryptorchi- 
dia, hidden testicle, according as one or both of these spermatic organs are 
iiffected. It is then of these anomalies that the memoir of M. Godard treats. 
The anomaly that consists in the complete absence of one or of both testicles, 
of which undoubted examples have been reported, one of them in the twenty- 
third volume of this Journal (old series),' is not considered by him ; he merely 
relates some facts for the purpose of showing that it is an anomaly really existing. 

The researches of M. Godard go to show that monorchidia, which is the vice 
of conformation first treated of, is the result of an anatomical defect ; of an error 
of diagnosis which has led to the application of a bandage for the purpose of 
retaining a hernia supposed to exist ; or of a spasmodic contraction of the cre- 
master muscle. 

The anatomical causes may belong to the testicle, to the gubernaculum testis, 
and to the pillars of the inguinal canal. Examination after death in the new- 
born child, has shown the testicle so swollen from inflammation that it could not 
pass through the abdominal ring ; and moreover, the existence of a local peri- 
tonitis causing its adhesion to neighbouring organs. Lesions of the gubernacu- 
lum testis are, more often than is generally supposed, the primary causes of this 
vice of conformation. It is, most probably, owing to the contractions of the 
gubernaculum that the testicle descends from the place where it is first deve- 
loped in the neighbourhood of the Wolffian bodies downwards to the scrotum. 
When the gubernaculum is completely wanting, the testicle remains where it 
was developed. The fibrous rings of the inguinal canal, above all the external, 
are sometimes so narrow as to prevent the descent of the testicle. 

When a child has, in the inguinal region, a movable reducible tumour, the 
mistake is sometimes made of applying a truss, which will permanently prevent 
the passage of the testicle out of the abdominal cavity. This mistake is gene- 
rally made by a bandagist, as M. Godard says ; but very capable men may be 
supposed to make this mistake at times, from want of care in making the exami- 
nation. In the October number of this Journal, for 1848, page 348, a case is 
reported by a fleet surgeon in the American navy, in which he had treated for 
some time an inflamed testicle situated in the inguinal canal as a strangulated 
hernia. 

Spasmodic action of the cremaster muscle is very rarely the cause of monor- 
chidia. M. Godard has been able to collect but two examples of it. In these 
cases the testicle, after its descent into the scrotum, was raised up again into the 
inguinal canal by the action of this muscle, and became fixed there. 

In the numerous cases observed by M. Godard, 58 in number, in which one 
testicle had come down into the scrotum and the other not, sometimes both 
organs were healthy, at others one of them had undergone a change, and at 

' In an article entitled, " Contributions illustrative of the Functions of the Cere- 
bellum," by John D. Fisher, M. D., of Boston. 



1859.] 



GoDARD, Monorchidie et la Cryptorcliidie. 



207 



others again both were in a pathological condition. All these cases are, there- 
fore, arranged in four great divisions, as follows : — 

1st. The descended testicle and that of the opposite side arrested in its evolu- 
tion are in the normal condition. 

2d. The descended testicle is normal, that which has not descended being 
diseased. 

3d. The descended testicle is in a pathological condition, that of the opposite 
side arrested in its evolution being healthy. 
4th. Finally, both organs are diseased. 

Each of these divisions offers some varieties according to the side where the 
anomaly has its seat, and the place in which the testicle has stopped. The diag- 
nosis, the prognosis, the consecutive accidents, the pathological anatomy, the 
condition of the testicle, and the means to be adopted to facilitate its descent, in 
all these manifold varieties, are carefully and ably treated of. In the majority 
of these cases, the descended testicle was healthy ; that is, it did not bear marks 
of disease. The examination made of its structure, however, showed that it was 
not performing its functions, that it was not acting as an organ of generation. 
When cut open, the gland had its normal colour, and its consistence was the 
same with that of the descended testicle. The seminiferous cones were arranged 
as in the normal condition, and no difference could be observed, by the aid of the 
microscope, in the canaliculi. The liquid extracted from the canaliculi did not 
contain any spermatozoa ; only nuclear epithelium, globules of blood, and some 
fatty globules. Upon an examination of the epididymis, not a trace of sperma- 
tozoa could be seen in the liquid contained in the canaliculi, nothing but cylin- 
drical epithelium. The seminal vesicle of the same side never contained sper- 
matozoa. 

In the absence of any other cause for the non-secretion of spermatozoa in the 
arrested testicle, and recollecting the fact that it is always fixed and motionless 
in the place it occupies, M. Godard concludes that the organ does not secrete 
because it does not possess the mobility it ought to have, and which it enjoys in 
the scrotum, where every moment it is subject to the contractions of the cre- 
master muscle. 

The consequence of this capital fact is, that in cases where monorchidia exists 
the testicle in the scrotum is the only one that serves in generation. 

It was an idea of the ancients, and it is still held by some persons, that the 
sex of the child depends upon the testicle that provides the semen by which the 
ovule is fecundated. Hippocrates, for example, says that, in order to have a girl, 
the man should tie the right testicle as firmly as he can bear it ; to have a boy, 
he should tie the left.* Numerous observations recorded by M. Godard show 
that persons having but one testicle in the scrotum, consequently but one active 
organ, have children of either sex. 

It being a matter then of the greatest importance that the testicle should 
descend into the scrotum, nothing should be neglected that could further its 
descent. The means recommended by M. Godard, as a general rule, are gym- 
nastic exercises, swimming, and violent movements ; of course, these means must 
be carefully watched and employed with discretion. 

By cryptorchidia, M. Godard means that vice of conformation consisting in 
the absence of testicles in that portion of the integument that corresponds to the 
scrotum. This condition of things, very rare in men, constitutes, as is well 
known, the normal state of the greater number of animals. Its causes are iden- 
tically the same as those of monorchidia. It cannot, however, be hereditary, as 
monorchidia sometimes is, unless it be in a family such as that of the Irishman, 
where it was hereditary not to have children. From the observations made by 
M. Godard, it is proven beyond a doubt, that men whose two testicles are 
arrested in their evolution are not impotent, but sterile. 

The text of this memoir is illustrated by a large number of figures, and by 
three large lithograph plates. 

By the manner in which the Biological Society of Paris issues its Gomptes 
Rendus and Memoirs, it is well seen how well they appreciate the fact that a 



' Littre's translation into French. Vol. viii. p. 501. 



208 



Bibliographical Notices. 



[Jac. 



society is what it does, if we may so express ourselves. Judging of it in this 
way, we must look upon it to the medical man as one of the most important 
societies in the world. . W. F. A. 



Art. XXYII. — On Amputation hy a Long and a Short Rectangidar Flap. 
By Thomas P. Teale, F. L. S., F. E. C. S., Surgeon to the Leeds General Infir- 
mary. Illustrated by engravings on wood by Mr. Bagg. London : Churchill, 
1858. 8vo. pp. 72. 

The question as to the best mode of performing an amputation has ever been 
a somewhat unsettled one. Even at this day we can recognize in the surgical 
ranks the existence of two distinct parties — those who advocate the circular ope- 
ration, and those who prefer to amputate by the method of single or double flaps. 

Mr. Teale, the writer of the little volume before us, states, in his general remarks, 
that he has at different periods of his life practised both methods of operating. 
Finding, however, that neither of these were entirely free from certain objections, 
Mr. Teale has devised a plan of proceeding which affords, in his estimation, results 
of a much more satisfactory character than either of those ordinarily employed. 
In performing an amputation, the author cuts two flaps, both of these being of a 
perfectly rectangular shape. The two flaps, however, vary much in size; the 
external one, as a general rule, being four times the length of the internal and 
shorter one. The vessels and nerves of the limb are always to be comprised in 
the lesser flap. When the flaps are cut, the long one — equal in length and breadth 
to one-half the circumference of the limb, and consequently a perfect square — is 
allowed to fall easily over the end of the bone ; its lower extremity is then brought 
up, and united by points of suture with the angles and extremity of the short flap. 
A stitch or two is also inserted, in order to unite the reflected with the unreflected 
portion of the greater flap. It must be observed, also, that in making the dissec- 
tions above described, care is taken to separate the soft parts from the bone, close 
to the periosteum, so as to preserve to the greatest extent the tissues necessary 
to form the pad or cushion of the stump. 

The chief peculiarity of the operation, as thus described, will be seen to be the 
obtaining of a sufficiently large fleshy mass for the covering of the end of the 
bone. The stump thus formed will be of large size, soft, movable over the sawn 
end of bone, and devoid of all large vessels or nerves. It will, consequently, be 
well fltted to sustain the necessary amount of pressure ; and the frequently occur- 
ring evils of a painful and irritable cicatrix will be by these means entirely ob- 
viated. 

In order to substantiate the conclusions at which he has arrived, Mr. Teale 
presents us with the following summary of cases which have been operated upon 
by his new method : — 



56 Amputations . . 



(From June 16, 1855, 
to June 16, 1858.) 




Death, 
Eecovery, 
Deaths, 
Eecoveries, 
Death, 
Eecovery, 
Death, 
Eecoveries, 
Death, 
Eecoveries, 
Deaths, 
Eecovery, 
Death, 
Eecovery, 



0. 
1. 
3. 
14. 
0. 
1. 
1. 
26. 
1. 
2. 
2. 
1. 
0. 
1. 
0. 
3. 




Accident, 




Disease, 




1859.] Brown-Sequard, Journal of Physiology. 



209 



By glancing the eye over the above table, it will be seen that of 6 cases of am- 
putation for accident, only one death occurred; and this death, we are informed, 
was caused by shock. In the annexed tabular statement of the result of 24 am- 
putations, according to the ordinary methods, performed during the same period, 
at the same hospital, and by the same surgeons, the mortality is stated as being 
vastly increased ; thus, of 17 amputations for accident, 10 died, and of these 10 
deaths, 7 were the result of putrid or purulent poisonings. 

Table of Amputations hy Ordinary Methods. 
Thigh, 2. ^ ^ 



24 Amputations . . 

(From June 16, 1855, 
to June 16, 1858.) 



Leg, 



Arm, 



12. 



Forearm, 5. 



Accident, 


2. 


Disease, 


0. 


Accident, 


6. 


Disease, 


6. 


Accident, 


5. 


Disease, 


0. 


Accident, 


4. 


Disease, 


1. 



{ 



Death, 


1. 


Recovery, 


1. 


Death, 


0. 


Recovery, 


0. 


Deaths, 


3. 


Recoveries, 


3. 


Deaths, 


0. 


Recoveries, 


6. 


Deaths, 


4. 


Recovery, 


1. 


Death, 


0. 


Recovery, 


0. 


Deaths, 


2. 


Recoveries, 


2. 


Death, 


0. 


Recovery, 


1. 



Why so great a difference as to the rate of mortality should exist between the 
proceedings of Mr. Teale and those ordinarily employed, we confess we are unable 
to understand, and we cannot see how it is to be charged simply to the different 
mode of making the incisions. It would seem to us, also, that after the formation 
of so large a flap there might perhaps be some tendency to non-union, or to slough- 
ing, a point upon which the author is silent. Be this, however, as it may, the 
favourable statistics of the modified operation with which we are presented will 
undoubtedly lead surgeons to give Mr. Teale's method of amputation a fair trial, 
since the drawings of the stumps, photographed some months after the operation, 
are such as will compare most favourably with those obtained by any other pro- 
cedure. J. H. B. 



Art. XXYIII. — Journal de la Physiologie de V Homme et des Animaux. Publie 
sous la Direction du Docteur E. Brown-Sequard. Tome premier, Numero 
III. Juillet, 1858. 

The Physiological Journal of Brown-S6quard, which has now reached its third 
number, continues to maintain the high character which distinguished the first 
and second numbers, and which we have already adverted to in former notices 
of this periodical. 

The present number contains twelve original contributions, besides the trans- 
lations and extracts from other periodical publications. The original memoirs 
are as follows : — 

1. Memoir on Hybridity in general, on the Distinction of Animal Species, and 
on the Hybrid of the Rabbit and Hare. By M. P. Broca. 

2. On some New Facts relative to Epilepsy following Injuries of the Spinal 
Cord. By M. Brown-S6quard. 

3. Researches on the Erectile Organs of the Female, and on the Muscular 
Tubo-Ovarian Apparatus in their connections with Ovulation and Menstruation. 
By M. Ch. Rouget. (With a plate.) 

4. Researches on some of the Effects of Cold on Man. By MM. Tholozan and 
Brown-S6quard. 



210 



Bibliographical Notices. 



[Jan. 



5. Eemarks on the preceding paper. By M. Brown-Sequard. 

6. On the Suspension of the Kadial Pulse by Forced Extension of the Arm. 
By M. Yerneuil. 

7. On the Association of Inspiratory Efforts with a diminution or arrest of the 
Movements of the Heart. By M. Brown-Sequard. 

8. On the Occlusion of the Superior Orifice of the Larynx and Pharynx during 
Inspiratory and Expiratory Efforts. By M. E. Smith. (With two figures.) 

9. Eesearches relative to the Physiology and Pathology of the Annular Pro- 
tuberance. By M. Brown-S6quard. 

10. On the Origin of Sugar in the Chyle. By M. S. Colin. 

11. Experimental Eesearches relative to the possibility of the passage, through 
the Nervous Centres, of Electro-Magnetic Currents applied to the Skin of Man. 
By M. F. Bonnefin. 

12. On the Formation of Glucose in the Animal Economy. (Eeport made to 
the Academy of Medicine.) By M. Poggiale. 

All these articles exhibit ability in the authors, and several of them are of a 
highly important character. We may cite, for instance, the memoir on hybridity, 
by M. Broca, and that of M. Colin " On the Origin of Sugar in the Chyle," as 
being of much interest, and as specially deserving of consideration. 

Dr. Isaac's valuable memoir on the kidney is translated entire, and illustrated 
with the original drawings of the author, and the labours of several other 
American writers are noticed appropriately. W. A. H. 



Art. XXIX. — Hie Science and Art of Surgery : being a Treatise on Surgical 
Injuries, Diseases, and Operations. By John Erichsen, Professor of Surgery 
and of Clinical Surgery in University College, and Surgeon to University Col- 
lege Hospital. Second edition, enlarged and carefully revised. Illustrated by 
400 engravings on wood. London : Walton & Maberly, 1857. 8vo. pp. 1040. 

As a general text-book on surgery there is perhaps no work which justly occu- 
pies so high a position as the treatise of Mr. Erichsen. That this is the case 
has been most amply proven by the rapidity with which the first edition, both 
English and American, has been exhausted. In the preface to the new edition we 
are informed by the author that he has spared no pains in revising his original 
work, that much of it has been entirely rewritten, and that he has endeavoured to 
render the additions which he now makes of an essentially practical character. 
In this efi'ort Mr. Erichsen has most happily succeeded ; many of the subjects 
which were previously somewhat meagre in description, having in the new edi- 
tion been faithfully described. The general arrangement, however, of the volume 
is the same, although the great amount of fresh matter interspersed throughout 
gives it almost the character of a different book. 

In the recent issue we observe that the author has devoted several pages to the 
subject of the administration of anaesthetic agents, a topic which, fraught with 
such vital interest to the surgeon, is too frequently most summarily dismissed by 
the various writers on surgery. The present volume is also enriched by the intro- 
duction of numerous cuts, so that it may now be considered as being fairly illus- 
trated ; in this respect presenting a very great superiority over the work as ori- 
ginally presented. The index also exhibits marks of great improvement, being 
copious. The first appearance of Mr. Erichsen's publication did much to en- 
hance the reputation, already great, of its distinguished author amongst his bre- 
thren on this side of the Atlantic. That this reputation will not now suffer, we 
are well convinced, from a careful perusal of the pages of the second edition. 
As a comprehensive treatise on surgery, Mr. Erichsen's is undoubtedly the 
favourite in this country, and we feel assured that its speedy reissue will be 
again most heartily welcomed. J. H. B. 



9 



1859.] 



Watson, Principles and Practice of Physic. 



211 



Art. XXX. — Lectures on the Prmciples and Practice of Physic, delivered at 
King's College, London. By Thomas Watson, M. D., Fellow of the Royal 
College of Physicians, late Physician to the Middlesex Hospital, etc. A new 
American, from the last revised and enlarged English edition. With addi- 
tions, by D. Francis Condie, M. D., Fellow of the College of Physicians of 
Philadelphia, etc. etc. With one hundred and eighty-five illustrations on 
wood. 8vo. pp. 1224. Blanchard & Lea : Philadelphia, 1858. 

It may be confidently asserted that no work on the Practice of Physic has 
ever received more universal commendation than has that of Dr. Watson. The 
author possesses the happy faculty of giving to the dry relation of pathological 
facts, and the uninteresting details of therapeutical appliances, not simply clear- 
ness and exactness, but actually attractiveness. His style, which is plain, simple, 
almost conversational, is, at the same times, graceful, accurate, and forcible, 
and all his teachings clear, full, and precise. His lectures possess a fascination 
of manner which is to be met with in the purely practical writings of no other 
physician of modern times, with an extent and copiousness of scope, and an 
accuracy and completeness in the handling of the several subjects embraced in 
them which has heretofore been scarcely attained. 

Borrowing without stint from the vast fund of medical knowledge accumulated 
by the joint labours of the physicians, as well of former years as of the present 
day ; testing the value of every assumed fact — old or new — by the well-established 
principles of general pathology and therapeutics, and the result of his own clinical 
observations, the teachings of Pr. Watson have a copiousness, accuracy, and 
earnestness, which cannot fail to convey to the mind of the student, with the 
desired truthfulness and vividness, the knowledge they are intended to teach ; to 
inculcate those principles in medicine which have received the sanction of the 
best minds in the profession, and those plans of treatment which come to us 
indorsed by the experience of the most successful practitioners of the healing art. 

The work is an eminently practical one, in the proper acceptation of the term. 
The great object of the author is, on the one hand, to teach his readers how to 
know, distinguish, and judge disease, and, on the other, how best to treat it, in 
order to abate the suffering and insure the safety, as far as possible, of the 
patient. To this end, physiology, pathology, histology, and organic chemistry 
are called in, whenever their aid is available, to explain, correct, and embody 
the facts derived from simple observation — to enlighten, in other words, the 
teachings of empiricism. Dr. Watson is, however, no theorist ; neither does he 
allow himself to be led astray by the results of hasty observations, or too rapid 
conclusions from badly established premises or imperfectly observed facts. He 
is wary of all novelties, and treats with proper contempt high-sounding terms, 
which have a semblance of knowledge without the substance ; but, at the same 
time, he is a firm believer in the progress that medicine has already made, and 
which it must still continue to make. 

The lectures of Dr. Watson, as they appear in the edition before us, present 
a full and faithful exposition of the actual state of the theory and practice of 
medicine, with all the improvements it has of late years received from the physi- 
cians of almost every portion of the civilized world. They are generally con- 
ceded to be, at once, the most complete and practical treatise of physic extant ; 
the best adapted to the wants of the student, from their exactness, clearness 
and simplicity, and to those of the practitioner from their copiousness and 
accuracy. 

In the present edition, the work has undergone a thorough revision ; every- 
thing of value which has been recently added to our store of knowledge in the 
various departments of medical science, will be found incorporated in it, whether 
in reference to the etiology, pathology, and treatment of the different forms of 
continued fever; the physiology and pathology of the spinal cord; the recent 
researches on fatty degeneration of the heart and other organs ; cardiac coagula, 
and the occlusion of arteries by travelling cardiac vegetations ; affections of the 
supra-renal capsules; the influence upon the endo and pericardium of injections 



212 



Bibliographical Notices. 



[Jan. 



of lactic acid into tlie cavity of the peritoneum ; diseases of tlie stomach, and on 
the actual value and proper employment of bloodletting as a remedy in inflam- 
mation ; embracing an exposition of the views, experiments, and observations of 
Drs. Jenner, Brown-Sequard, Todd and Gull, Quain, Garrod, Kirkes, Brinton, 
Addison, and Richardson, Mr. Lochart Clarke, and a host of others, who, of late 
years, have perfected and enlarged almost everything in relation to medicine, 
both as a science and an art. 

So copious have been the additions made by the author in the present edition, 
that the work is extended over two hundred pages, "notwithstanding a very 
considerable enlargement in the page." 

It might be supposed that to a work, like that of Dr. Watson, of which the 
accuracy and fulness are so universally confessed, no opening would be found 
for any additions or annotations on the part of the American editor. Neverthe- 
less Dr. Condie has, by a judicious exercise of his editorial functions, succeeded 
in increasing the interest and value of these lectures generally, but more espe- 
cially to the American student and practitioner. His annotations are mostly 
just, and his additions pertinent and well drawn up. Independently of the 
proper textual additions, he has also augmented considerably the number of 
illustrations beyond those of the latest London edition, and thus considerably 
increased its attractiveness, which, in itself, is a merit of no small importance, 
as tending to a wider diffusion of its valuable teachings. 

In its present form, the work is not only a valuable, but an indispensable, addi- 
tion to the library of every physician ; so that the members of the profession owe 
many thanks to the American publishers, for offering it to them in so attractive 
a form, as respects paper, typography, illustrations, and binding, and at a price 
80 low as to place it within the reach of even the poorest among them. 



Akt. XXXI. — A Practical Treatise on the Causes, Symptoms, and Treatment 
of Spermatorrhoea. By M. Lallemand. Translated and edited by Heney J. 
McDouGALL. Third American edition. 

To which is added : On Diseases of the Vesiculce Seminales and their Associated 
Organs ; with special reference to the Morbid Secretions of the Prostcdic and 
Urethral Mucous Membrane. By Marris Wilson, M. D. Philadelphia: 
Blanchard & Lea, 1858. 8vo. pp. 380. 

The treatise of Professor Lallemand is well known in this country. A trans- 
lation, made by William Hood, M. D., of Portland, Me., was published in this 
city as long ago as the year 1839, and, as the title page of the volume before us 
states, this is the third American edition of the translation made in England by 
Mr. McDougall. 

Notwithstanding the very favourable reception this treatise has met with from 
the profession generally, and the laudations which have been bestowed on it by 
the medical journals, it has, we believe, been productive of much harm, having 
taught a most injurious mode of practice — the cauterization of the urethra — 
and led many to resort to advertising charlatans for relief. 

The work of Marris Wilson, which has been appended to this edition of the 
treatise of Lallemand, seems to us to be a fit companion, teaching what we re- 
gard as equally objectionable modes of treatment. We may instance the follow- 
ing, which we give in the author's own words : — 

" I am in the habit of applying a strong solution of the nitrate [of silver] to 
any single part of the canal, by using a curved glass syringe — a catheter, in fact 
— with an opening on the back of the curve near its extremity, the instrument 
having a small globe of India rubber attached to its external end. The opening 
is made to pass over every part to which it is required to apply the caustic solu- 
tion, and a slight pressure kept upon the India rubber globe always brings a 
fresh quantity of the solution to the opening" (p. 372). 

It is entirely unnecessary for us to make any reflections on such a mode of 
treatment as the one thus recommended. 

A remarkable case is recorded in this publication of Dr. Wilson, in which, for 



1859.] 



Malgaigne, a Treatise on Fractures. 



213 



the relief of spermatorrhcea, the left testicle was removed, and by Sir Astley 
Cooper; not being relieved, the right was amputated, but the erections and 
emissions, both diurnal and nocturnal, were as frequent as before. Then, under 
the supposition that the prostate was the seat of the disease, pieces of potassa 
fusa were introduced into the gland, for the purpose of destroying it. This treat- 
ment is now being pursued. Distinct emissions continue to take place, but at 
long intervals, the fluid being considerably less in quantity ! (pp. 338-40.) Cur- 
ling relates a case where a gentleman in the upper ranks of life was castrated, 
on account of most distressing self-pollutions. The patient committed suicide ; 
and the surgeon who had been rash enough to emasculate him, was threatened 
by the patient's friends with an action at law for performing so unwarrantable 
an operation. [Practical Treatise on the Diseases of the Testis, Philad. 
1856, p. 338.) 

In the treatment of spermatorrhoea, the best surgeons confine their interference 
to general treatment ; cauterization, which they were induced to try by what is 
said in its favour in the romance of Lallemand, they soon abandoned. We 
believe, ourselves, that the advice given by an eminent author, whose writings, 
though extensively disseminated of late, are little heeded, is that from which the 
greatest benefit is sure to come: 8e TtvsvjAati tas rtpd^ft^ rou crw^aro? davarovti, 
}r^6sads. (E'Tttf. rtpocr Pw H'. ty'.) W. F. A. 



Aet. XXXII. — A Treatise on Fractures. By J. F. Malgaigxe, Chirurgien de 
I'Hopital Saint Louis. With one hundred and six illustrations. Translated 
from the French, with notes and additions, by John H. Packard, M. D. Phila- 
delphia : J. B. Lippincott & Co., 1859. 8vo. pp. 683. 

M. Malgaigne's most excellent and elaborate work on fractures and disloca- 
tions has been so long and so favourably known to the profession, as to render 
unnecessary any extended notice at the present time. It affords us, however, 
sincere pleasure to be able to welcome the appearance, in an English dress, of 
the first volume of this valuable treatise. The translator, Dr. Packard, undoubt- 
edly deserves the thanks of the profession for the zeal and fidelity with which 
he has discharged the labour of rendering into English this volume on fractures. 
The annotations which he has appended to it are numerous, and appear to us 
to be of much practical value, adapting, as they do, the treatment of fractures 
to the generally received and most approved American methods. 

The original illustrations of M. Malgaigne's work were comprised in a large 
folio atlas of lithographic plates. For the convenience of readers, and facility 
of reference, these have been faithfully reduced one-half, and have been collected 
at the end of the volume, with an explanatory text attached. The general ap- 
pearance of the volume is extremely satisfactory, and reflects much credit on 
the translator. We trust that its success may be such as to warrant the speedy 
presentation of the remaining portion, which treats on dislocations. 

J. H. B. 



Art. XXXIII. — A Treatise on the Venereal Disease. By John Hunter, F. R. S. 
With copious additions, by Dr. Philip Ricord, Surgeon of the Hopital du 
Midi, Paris, etc. Translated and edited, with notes, by Freeman J. Bumstead, 
M. D., Lecturer on Venereal at the College of Physicians and Surgeons, N. Y., 
Assistant Surgeon to the New York Eye Infirmary. Second edition, revised, 
containing a rSsumS of Ricord's recent Lectures on Chancre. Philadelphia : 
Blanchard & Lea, 1859. 

Hunter's Treatise on the Venereal Diseases, with the additions made to it by 
M. Ricord, is almost universally acknowledged to be the best work that has ever 
been published upon the subject of which it treats. 

Hunter was resolved, as he said himself, that this work should not be a mere 
bookseller's job — each subsequent edition rendering the former useless. The 



214 



Bibliographical jSTotices. 



[Jan. 



greatest of sypliilographers, whether living or dead, although teaching doctrines 
widely different from those of Hunter, was not able to teach them better than 
by means of this treatise, the facts contained in which, some additional facts, 
observed by himself, show to have been wrongfully interpreted. 

In this new edition of Eicord and Hunter, the American editor has made a 
number of very valuable additions, the most important of which are taken from 
the publication recently made by M, Fournier, of the lectures on chancre re- 
cently delivered by M. Eicord, at the H6pital du Midi; a review of which publi- 
cation is contained in the April number of this journal for the past year. 

The editor states in his preface, "that the present edition of 'Eicord and 
Hunter' contains the fullest exposition of the views of M. Eicord that has yet 
been published." In this we fully concur, and would add, that it is the best 
arranged, most instructive, and most valuable work that has ever appeared on 
the subject of the venereal disease. "W. F. A. 



Art. XXXIV. — The Modern Practice of Midwifery : a Course of Lectures on 
Obstetrics, delivered at St. Mary's Hospital, London. By Wm. Tyler Smith, 
M. D., Member of the Eoyal College of Physicians. With an Introductory 
Lecture on the History of the Art of Midwifery, and copious Practical 
Annotations, by Augustus K. Gardiner, A. M., M. D., late Instructor on 
Obstetrics in the New York Preparatory School of Medicine, Author of the 
" Causes and Curative Treatment of Sterility," etc. Illustrated by 212 en- 
gravings. 8vo. pp. 760. E. M. DeWitt: New York, 1858. 

This work is simply a reprint, in book form, of the lectures of Dr. Tyler Smith, 
which appeared in the London Lancet during the year 1856 ; such additional 
matter as is contained in the subsequently published manual, by Dr. Smith, of 
theoretical and practical obstetrics (London, April, 1858), being inserted, as far 
as practicable, in its appropriate locality ; with an introductory lecture, and 
sundry annotations and additions, interspersed throughout the text, by the 
American editor. 

Having very recently had occasion to express our opinion in reference to the 
doctrines and practice of midwifery, as taught by Dr. Tyler Smith, and the man- 
ner in which these doctrines and practice are set forth and illustrated by him, in 
a notice by us of the manual just referred to, which, as the author states, com- 
prises the substance of his previously published lectures, differently arranged, 
and with such alterations and additions as give the work, to a certain extent, a 
character of originality, it will not be necessary for us to repeat here the re- 
marks we then made. 

While we feel no desire to dispute the statement of Dr. Gardiner, that the 
volume before us "differs" but "little from the author's revised edition," we 
must very candidly say that we doubt the propriety — waiving the question of 
right— of issuing the work of Dr. Smith in its present form, after the author had 
himself thought fit to recast it into an entirely new and different one; evidently 
intending that the form of manual should supersede that of lectures. To every 
author must unquestionably be conceded the right of deciding for himself the 
particular shape in which he shall appear in print before the public ; and even 
though it may be agreed that his decision, in this respect, has been the result of 
an evident error of judgment, still, no one who shall undertake to edit his works 
has a right to rectify — without the author's privity and consent — the error, any 
more than he would have to suppress or modify any portion of the text. 

Excepting this one circumstance of his not having followed, in matter and in 
plan, in the American edition of Dr. Tyler's work on obstetrics, the latest Lon- 
don edition — remodelled and revised by the author — the editor has fulfilled his 
duties, upon the whole, in an acceptable manner. The preliminary lecture, on 
the history of the art of midwifery, though but a sketch, is, to say the least of 
it, interesting and instructive, while his practical annotations, together with his 
lecture on the operations upon the os and cervix uteri demanded in cases of 
rigidity of the latter parts, are, in the main, sound and judicious. D. F. 0. 



1859.] 



Braun, Convulsions of Pregnancy, etc. 



215 



Art. XXXY. — The TJrcemic Convulsions of Pregna7icy, Parturition, and 
Childbed. By Dr. Carl R. Braun, Professor of Midwifery, Vienna. Trans- 
lated from the German, with Notes. By J. Matthews Duncan, F. R. C. P. E., 
Lecturer on Midwifery, etc. etc. 12mo. pp. 182. S. S. & W. Wood, New 
York. 1858. 

The work before us consists of a translation into English of one of the chap- 
ters of the Lehrbuch der Geburtshulfe, the text-book of midwifery of Professor 
Charles R. Braun, of the University of Yienna, which appeared in the early part 
of 1857. Dr. Duncan, of Edinburgh, informs us that he undertook the transla- 
tion of this portion of Professor Braun's treatise from a conviction of its value, 
as well in respect to the importance of the subject of which it treats as from its 
completeness and erudition. The translation was first published in the Edin- 
burgh Medical Journal, and subsequently in its present separate form, partly, 
as we are informed, " in consequence of the reception it had already met with, 
and partly from the utter deficiency of any similar treatise in the English lan- 
guage." 

The pathology of eclampsia as it occurs in the pregnant, parturient, and puer- 
peral female, has occupied the attention of some of the most distinguished 
obstetricians of the past, as well as of the present day. Unfortunately, how- 
ever, the observations heretofore made in reference to the disease have not 
been of a character to throw much light upon either its remote or direct causes, 
or to settle with certainty its true character and most successful treatment. 

It is more than probable that under the general denomination, eclampsia 
puerperalis — puerperal convulsions — there are included convulsive affections 
dependent on different and very dissimilar causes. In the chapter of his recent 
work on midwifery, the translation of which is before us. Professor Braun has 
endeavoured to show that, what he denominates " true puerperal eclampsia," is 
always intimately connected with albuminous diabetes, or Bright's disease of the 
kidneys, in an acute form, "which, under certain circumstances, spreads its 
toxsemic effects on the nutrition of the brain and entire nervous system." 

"The toxaemia, or blood poisoning, in the eclampsia of the pregnant, partu- 
rient, and puerperal conditions, is," Prof. B. remarks, " commonly produced by 
uraemia ; that is, by a change in the urea which has been retained in the blood, 
or by retention of excrementitial extractive matter of the urine. Hence, accord- 
ing to the present state of our knowledge, true eclampsia during pregnancy is 
designated urcemic ; without, however, implying that it is peculiar to pregnancy 
or child-bearing ; because the same disease, with similar phenomena, may mani- 
fest itself, also, in women not pregnant or in childbed, and even in males under 
certain favourable conditions." 

Professor Braun is very far from denying that the most dissimilar causes may, 
during the period of pregnancy, as well as out of it, produce phenomena resem- 
bling those of uraemic eclampsia ; but, after a careful examination of descriptive 
and statistical observations, by himself and others, he thinks that he is permitted 
to maintain the position, " that acute Bright's disease and ursemic poisoning of 
the blood are the true causes of puerperal eclampsia." 

The coincidence of eclampsia and albuminuria is a fact that has been abund- 
antly verified by the numerous observations of Simpson, Lever, Cormack, and 
others, of Great Britain ; of Develliers, Regnault, Dubois, Danyau, Cazeaux, and 
Blot, of France ; and of Helfft, Frerichs, Litzmann, Wieger, Oppolzer, Braun, 
and others, of Germany, as well as by the daily observations of medical practi- 
tioners everywhere. 

An oedematous intumescence of the external parts of the body, often of the 
face, arms, and hands, but more generally of the ankles, feet, and labia majora, 
is a common phenomenon preceding and accompanying puerperal convulsions, 
and such intumescence is, also, one of the most frequent symptoms of Bright's 
disease. The oedema is not always permanent, but appears when the patients 
are in a recumbent position, and disappears when they arise. It sometimes de- 



216 



Bibliographical Notices. 



[Jan. 



creases towards the end of pregnancy, and not unfrequently disappears alto- 
gether, even while sometimes the albuminosity of the urine and the morbid 
process in the kidneys are increasing. It is only when in pregnant women the 
oedema is connected with the presence of albumen, fibrin cylinders, and fatty 
degenerated scales of 'Bellini's epithelium in the urine, that they have any con- 
nection with urjBmic eclampsia. 

" Frerichs," says Prof. B., " has often found the oedema already developed in 
the third month of pregnancy, although far more frequently it is first observed 
in the last four months, often, however, without attracting attention, as the other 
less obvious features of the morbus Brightii are overlooked, although they are 
present. The more the pregnancy advances, the more the albumen in the urine 
increases, but disappears quickly after labour, sometimes within a few days, 
unless the exudative process in the kidneys makes further progress, and assumes 
the condition of chronic Bright's disease. But the dropsical swelling is not 
necessarily connected with this albuminuria, just as on the other hand there not 
unfrequently occurs, during pregnancy, a dropsy in which the urine is found 
quite normal." 

The symptoms," remarks our author, " of uraemia, which are observed in 
animals after the extirpation of both kidneys, are the same as those of the acute 
Bright's disease of pregnant women, in whom the diseased condition of the secre- 
tion and excretion of the kidneys causes pollution of the blood with excrementi- 
tial elements of the urine, a state which frequently, after headache, giddiness, 
drowsiness, delirium, coma, and convulsions, leads on to death." 

"Among the symptoms of uraemia, are also the diminished power of vision, 
amblyopia, and complete amaurosis. A pregnant woman, after headache, vomit- 
ing, or a condition of stupefaction, may be found altogether blind. We have 
also to enumerate here the humming in the ears, or the suddenly supervening 
partial deafness of pregnant women ; also a fever very like typhus, with diminu- 
tion or complete suppression of urinary excretion [Febris urinosa of Frerichs) ; 
in addition, a painful vomiting of tough or watery substance, in which the addi- 
tion of an alkali reveals the presence of ammoniacal compounds, but never of 
undecomposed urea. 

"These various phenomena appearing in the different regions of the body dur- 
ing life, leave no changes constantly discoverable after death. The brain and 
its membranes are then either exsanguine, natural, or engorged with blood ; the 
sac of the arachnoid, and the cerebral ventricles, contain sometimes, but not 
always, a serous effusion. The globe of the eye is, after urasmic intoxication and 
amaurosis, sometimes normal; sometimes it exhibits an increased secretion of 
aqueous humour, sometimes an exudation on the retina. 

"The degree of coagulation of the blood, when drawn from the veins, varies; 
it has a tinge of violet colour, sometimes an ammoniacal smell, distinctly remind- 
ing one of putrid urine, and it contains carbonate of ammonia — often in such 
quantity, that it effervesces on the addition of muriatic acid — with generally 
some remains of undecomposed urea. 

" The uraemic fits do not originate, as was formerly supposed, only from the 
blood being poisoned by urea. Filtered urine, injected into the veins of animals, 
has been tolerated without evil consequences. 

" In regard to uraemic intoxication, Frerichs has been led, by a series of care- 
fully performed experiments, to conclusions, which we have found confirmed in 
the cases of several pregnant women who suffered from eclampsia and acute 
Bright's disease. 

" (a). The phenomena of uraemic intoxication are produced neither by urea or 
any other ingredient of the urine, nor by the united excretory matters, as such, 
of this fluid; but they commonly arise from this circumstance, that the urea ac- 
cumulated in the blood is transformed into carbonate of ammonia under the in- 
fluence of some peculiar ferment. 

" (&). Carbonate of ammonia is the baneful power which produces these dis- 
turbances of the functions of the nervous system. 

" For the production of uraemic intoxication, it is therefore necessary to have 
in the blood quantities of urea, and the presence of some ferment, by means of 
which the urea may be changed into carbonate of ammonia. If the fermenting 



1859.] 



Braun, Convulsions of Pregnancy, etc. 



21T 



material is wantinf]^, then the blood may be for a long time impregnated with 
urea, without any injurious consequences appearing. In this way the fact is ac- 
counted for, that in the bodies of persons dead of Bright's disease, the blood 
may be found saturated with urea, without any urae-phenomena having been ob- 
served during life. The cause of this fermentation is, as yet, not altogether 
known." 

The theory of the identity of urasmic poisoning, from acute Bright's disease 
and puerperal eclampsia, has been strenuously opposed by Marchall, Depaul, 
Legroux, L'Huillier, Siebert, Stoltz, Seyfert, Levy, Scanzoni, and others. Those 
gentlemen maintain that the diseased condition of the kidneys often met with in 
the bodies of those who have died of eclampsia is the consequence and not the 
cause of the convulsions — an accidental secondary phenomena, only, of hyperae- 
mia caused by the eclampsia and the serous plethora — hydraemia — of pregnancy. 
This opinion they consider to be proved by the following considerations. It is 
only, they assert, in the minority of such as die of eclampsia that the changes 
discovered in the kidneys are sufficient to justify the diagnosis of Bright's disease. 
There is no evidence that the presence of albumen and fibrin cylinders in the 
urine always precede the convulsive attack. The arguments adduced to prove 
uraemic poisoning of the blood in cases of eclampsia, are not of themselves suf- 
ficient to prove that genuine puerperal convulsions are always the result of such 
poisoning as a consequence of Brightian degeneration of the kidneys. Puerpe- 
ral eclampsia, the objectors maintain, consists in general clonic convulsions of 
the voluntary muscles, proceeding from the spinal marrow, with absence of con- 
sciousness ; which convulsions have their immediate cause in the irritability of 
the motor system of nerves, the result of pregnancy and augmented by the act of 
delivery. 

In reply to these objections, it has been attempted to be shown that the exist- 
ence of Bright's disease is extremely common in those who have died from 
eclampsia, as is proved by the observations of Professors Braun, Gustav, Braun, 
Wedl, Lumpe, Hecker, Devilliers, Eegnauld, Hesse, Simpson, Sabatier, Hohl, 
and a host of others. That the indications of the presence of nephritic disease, 
soon after the appearance of convulsions are of too decided and extensive a cha- 
racter to allow us to suppose that such disease had been developed within the 
few preceding hours. That acute Bright's disease often precedes the occurrence 
of eclampsia is very certainly proved by numerous observations on record, and 
hence it is a probability, bordering on certainty, that a connection exists between 
the two. 

"The circumstance that eclampsia does not occur in every case of Bright's 
disease during pregnancy, may, as Litzmann has very correctly remarked, be 
accounted for by convulsions following only when the blood has been very consi- 
derably impregnated with the excrementitial elements of the urine, which always 
implies a very profound, or, at least extensive disease of the renal tissue." 

Albuminuria is said to occur more frequently in parturient and puerperal 
women than among the pregnant. In support of this position cases in which 
only a trace of albumen, without admixture of exudation clots, is to be detected 
in the urine, have been estimated as of equal importance with those cases where 
that copious excretion of albumen and of cylindrical clots takes place which is 
constantly met with in eclamptic patients. Litzmann was the first correctly to 
appreciate this occurrence of traces of albumen among lying-in women as a 
catarrh of the bladder, on account of the simultaneous presence of pus-globules, 
and the absence of exudation clots. He believes, also, that this cannot be re- 
garded even as a symptom of commencing Bright's disease. 

The supposed sudden and abundant appearance of albumen and of fatty dege- 
nerated cylindrical clots has not been proved by any convincing microscopical 
observations that have as yet been made public. 

According to the observations of Frerichs, Hasse, and the author, the most 
violent attacks of epileptic and hysterical convulsions, even when occurring re- 
peatedly during the same day, never have, as a consequence, albuminuria or 
excretion of cylindrical clots. In women, however, affected with habitual epi- 
lepsy, eclampsia may supervene, from Bright's disease, during pregnancy, labour, 



218 



Bibliographical Notices. 



[Jan. 



or cMldbed, When eclampsia appears during the puerperal state, it originates 
in Bright's disease, which had been already developed during pregnancy. 

Cases of unquestionable eclampsia from uraemia, dependent upon disease of 
the kidneys, and terminating fatally, have been recorded by Braun and Bam- 
berger, in a case of retroversion of the uterus, and by Picard, in a man affected 
with stricture of the urethra. 

" The first stage of Brightian kidneys, in which the exudation in the tubuli 
uriniferi is still fluid, and cannot be demonstrated by the microscope, or when 
the coagulated exudation appears periodically in the urine in large quantities, 
as cylindrical clots, and then again disappears for some time, must be regarded 
as a blood-poisoning disease, equally dangerous as the fatty metamorphosis of 
the kidneys. For Briicke's ingenious investigations on the casual connection of 
albuminuria and uraemia, have shown that the occurrence of uraemia depends 
not so much on the intensity of the structural changes as on the extent of the 
morbid exudation of the kidneys." 

If any value is to be ascribed to the careful chemical researches of Miahle, 
they afford sufficient grounds for our believing that copious albuminuria is not 
the product of hydraemia, but a primary exudation from the kidneys. 

According to Dr. Cormack, pregnancy produces an increased necessity for 
purification of the blood through the congested kidneys, and in this way defective 
secretion of poisonous excrements from the blood — i. e., toxaemia — is induced. 
The direct influence of this morbid blood on the brain, spinal cord, and medulla 
oblongata, causes convulsions. 

" If we hold, with Frerichs, Litzmann, the author, "Wieger, and others, that the 
ordinary cause of Bright's disease in pregnancy is the retardation of the stream 
of venous blood in the kidneys, from the compression of the venous trunks by 
the gravid uterus, then it is obvious that, in this circumstance, we have the cause 
of the abnormal process of exudation being more or less uniformly spread over 
the whole organ, without any immediate necessity for its texture undergoing 
more profound changes. On the contrary, such will probably appear only grii- 
dually, and after a long duration of the diseased action. It must always be kept 
in mind that it is possible to have one kidney only, or at least principally, 
aflccted, from the uterus ha^dng a peculiar position, as several cases already 
cited demonstrate. In this way, also, partly, the circumstance may be accounted 
for, as Litzmann has already remarked, that sometimes, in spite of the intensity 
of the local morbid process, no signs of uraemia appear, while in other cases 
uraemia is observed when the disease is much less intense, but probably affects 
both kidneys, in which case, the quantity of the urine does not always undergo 
a marked diminution." 

In proof of the uraemic intoxication from Bright's disease producing parturient 
eclampsia, for the most part by carbonate of ammonia in the blood, and perhaps 
also by extractive matters of the urine. Professor B. remarks: — 

" The investigations of Frerichs, Litzmann, the author. Heller, Kletzinsky, 
Oppolzer, Gegenbauer, and others, have demonstrated that in the eclamptic, urea 
and carbonate of ammonia, developed by its decomposition, are generally found 
in considerable quantity in the fresh blood ; that from the presence of these 
materials in the blood, the occurrence of uraemic eclampsia may be prognosti- 
cated, and that these substances are observed also in the iDlood of children born 
of urasmic mothers. 

" Chemical analysis, however, cannot always, even during the most violent 
eclampsia, discover the presence of carbonate of ammonia in fresh blood, as is 
shown in an observation made on the 14th August, 1854, by Gustav Braun and 
Holler. * * * In this observation, the blood was found not to have a uraemic, 
but a cholasmic, constitution ; as it contained no carbonate of ammonia, but all the 
elements of bile. This observation, although it does not stand alone, cannot be 
used to invalidate the theory of the very frequent coincidence of eclampsia and 
uraemia. It rather points out that the excrementitial elements of bile may, pro- 
ducing cholacmia in the living body, be likewise a cause of eclampsia." 

In reference to the theory of the intoxication of the blood by carbonate of am- 
monia, Dr. Litzmann's conclusions, after a careful consideration of the objections 
that have been urged against it, are : that the fresh blood of healthy individuals 



1859.] 



Bra UN, Convulsions of Pregnancy, etc. 



219 



never contains ammonia ; but that the latter is present in the blood in the ma- 
jority of the cases of uraimia, being formed there by the decomposition of urea 
formed and retained in the blood, or by the decomposition of urea that has 
been secreted into the urinary passages, and has returned into the circulation by 
absorption. 

" But," remarks Prof. B., " on the one hand, presence of ammonia in the blood 
is not, by any means, a sign of ura?mia exclusively, for it has been exceptionally 
observed [Reuling) in otlier diseased conditions {typhus, pyoimia), where the 
urinary secretion was not disturbed. On the other hand, cases undoubtedly 
occur where, notwithstanding obstructed secretion of urea by the kidneys, and 
the occurrence of all the characteristic symptoms of ursemia, the blood does not 
contain any ammonia, and the ammoniacal contents of the exhaled air are not 
increased [Reuling)-, but where, on the contrary, undecomposed urea is found 
in the transudations from the blood, and in the sweat especially, may be in 
such quantity as to be left on the skin in the form of a white crystalline dust 
[SchoUin, Fiedler). The cause of the urtemic phenomena cannot, therefore, be 
sought for in the decomposition only of the urea retained in the blood into car- 
bonate of ammonia." 

AYieger would regard ursemia not so loosely as the ancients, who held it to be 
a metastasis of urine, nor so exclusively as Frerichs, who considers it an intoxi- 
cation by carbonate of ammonia, but as a consequence of Brightian exudation 
into the kidneys, which, in its chemical relations, is characterized by retention 
of water and excrementitial matters in the blood, which itself, from the loss of 
blood-corpuscles and albumen, is impoverished in these elements. But it is im- 
. possible, according to our author, to say whether the chief part in the combined 
operation is to be ascribed to the excess of serum or to the diminution of the 
albumen and blood-corpuscles. Hydrasmia, however, he remarks, is never the 
cause of the nervous symptoms, but has only a predisposing action. 

"Eclampsia puerperalis is not," according to Prof. B., "a consequence of 
hydreemia of pregnancy, or of pains. For the following reasons, Bright's dis- 
ease cannot be regarded as the consequence of eclampsia : — 

" a. Blot's observations show that the average quantity of albumen in the 
urine is, in albuminuric individuals not suffering from eclampsia, 33 per cent. ; 
in the eclamptic, sometimes 74 per cent. But, from the quantity of albumen in 
the urine, we cannot decide whether eclampsia will occur or not, because the 
whole quantity of urine secreted in twenty-four hours, and of urea accumulated 
in the blood, may greatly vary. 

" b. From the analyses of Becquerel, Eodier, Devilliers, and Eegnauld, it ap- 
pears that the albumen in the blood of pregnant women is diminished 4 per cent., 
and in albuminuria 16 per cent. But hydraemia and diminished albuminous con- 
tents cannot be the cause of the escape of albumen into the urine, because, as 
"Wieger has shown, it would be impossible to explain why hydrsemic blood secretes 
a small quantity of urine ; why blood-globules often, and exudation clots alwaj's, 
appear in the urine ; why the absolute quantity of urea and of extractive matter 
secreted within twenty-four hours is diminished ; why, in post-mortem examina- 
tions of eclamptic patients, the kidneys so often exhibit extensive degenerations ; 
and how it can happen that, in cholera with an early stage of nephritis, conden- 
sation of the blood coexists with excretion of albumen. 

" c. Depaul has advanced the opinion that albuminuria is a consequence of 
eclampsia, inasmuch as, when it exists during pregnancy, it disappears a few 
hours after delivery, while it is often not till some days afterwards that eclampsia 
begins, and causes the reappearance of the albumen. 

"Wieger, founding his arguments on numerous observations made by the author, 
Blot, Regnauld, and Devilliers, has controverted this opinion in detailed statisti- 
cal tables. He shows that, in cases of distinct albuminuria, and of eclampsia, 
ths albumen does not disappear a few hours after delivery ; that this does not 
happen till two days at least, and often not till a week after ; that it often per- 
sists, and even increases ; that in women dying comatose, the albuminuria con- 
tinues till death ; and that the danger of eclampsia not unfrequently increases 
with the intensity of the albuminuria. 

"d The cases adduced by L'Huillier, Depaul, Dubois, Mascarel, and the 



220 



Bibliographical Notices. 



[Jan. 



author, in which, during puerperal eclampsia with fatal issue, no traces of albu- 
minuria could be discovered, prove only that, in pregnant women, convulsions 
may, in exceptionable cases, be produced by various causes, as meningitis, burns, 
typhus, capillary apoplexy, habitual epilepsy, anaemia, cholsemia, etc. They do 
not force us to take refuge, in a manner that cannot be justified, in a mysterious 
hypothesis of some peculiar condition of puerperality, in hydraemia, leukaemia 
{Bengel), oligocythaemia, hypernosis (Oldham), hypalbuminosis, etc., for the ex 
plauation of the ordinary form of the far more frequently occurring uraemic 
eclampsia." 

With Hasse, our author recognizes the truth, therefore, of the following pro- 
positions : 1. All cases of albuminuria in pregnancy and childbed, are not re- 
ferable to Bright's disease. 2. Only a few cases of Bright's disease go so far as 
to produce uraemia. 3. It is not a necessary result of uraemia, that every one 
suffering from it will have eclampsia. 4. The appearance of this affection is not 
necessarily connected with any particular stage or extent of degeneration of the 
kidneys. 5. The function of labour is not the immediate cause of eclampsia, nor 
do the spasms during the paroxysms stand in any connection with the coming 
on of uterine pains." 

In the foregoing analysis of the strictly pathological portion of Prof. B.'s 
remarks on puerperal eclampsia, we have endeavoured to present such an outline 
of his opinions in respect to the nature of the disease, and of the general argu- 
ments adduced in their support, as will bring them very fully to the notice of 
our readers, in order that they may be enabled to test their validity by the results 
of their personal observations. 

We proceed now to give a brief sketch of the treatment of uraemic eclampsia 
recommended by our author, based upon his views of its pathology. 

When at an early period of pregnancy hydraemia is developed, it may be 
somewhat ameliorated by a nutritious diet, vegetable tonics, and chalybeates, 
with the use of tepid and vapour baths. To neutralize the carbonate of am- 
monia formed in the blood by the decomposition of urea, the use of benzoic acid, 
lemon-juice, or tartaric acid is recommended by Frerichs. Congestion of the 
head is to be obviated by vinegar injections, aloes, jalap, etc. 

When exudation has taken place into the Malpighian capsules, and the 
tubuli of Bellini and Ferrien, if there is a copious secretion of urine, the removal 
of this exudation may sometimes be effected by the copious use of any mild 
diluents ; but when the secretion of urine is scanty, the best means for the re- 
moval of the exudation is the use of the acids named above, or the mineral waters 
of Seltzer or Yichy. 

To restore the normal tone, pills of tannin and extract of aloes are recom- 
mended by Frerichs. 

In cases of Bright's disease occurring during pregnancy, a question arises 
whether the induction of premature labour be admissible, with the view to pre- 
vent the venous congestion and the progress of degeneration in the kidneys. 
Prof. B. considers that artificial premature delivery is always improper, in the 
absence of all symptoms of uraemia ; but he is in favour of it when the severity 
of the albuminuria, the quantity of cylindrical clots, a high degree of hydraemia, 
considerable dropsical swelling, with dangerous disturbance of the functions of 
the heart, lungs, brain, etc., indicate the imminence of the patient's danger, more 
especially when we have good reasons for supposing the foetus to be dead. 

When, in patients affected with Bright's disease, without uraemia, labour sets 
in, to prevent the occurrence of convulsions, Chailly recommends the production 
of a slight degree of anaesthesia by the use of chloroform ; Prof. B. is in favour 
of this, also, in cases of metralgia and protracted labour, occurring in patients 
affected with Bright's disease. 

When uraemic eclampsia has occurred, our author recommends highly the in- 
duction of chloroform narcotism, as soon as any indication of an impending 
paroxysm is detected, and the continuance of the narcotism until such indication 
disappears, and a quiet sleep ensues. If, however, the convulsive paroxysm be 
not arrested, during its presence and the succeeding comatose state, the use of 
the chloroform he directs to be suspended, in order to allow an abundant supply 
of fresh atmospheric air to reach the lungs. 



1859.] 



Braun, Convulsions of Pregnancy, etc. 



221 



To obviate the secondary congestion of the head, and meninges of the brain, 
the local application of ice is recommended, or sprinkling- with cold water, or, 
as a means still more efficacious, the cold douche. Sponging the skin with 
tepLd vinegar produces, we are told, a most desirable diaphoresis, and is easily 
accomplished. 

Prof. B. condemns general bloodletting, in uremic eclampsia, as being calcu- 
lated to increase the hydremia and aggravate the convulsive paroxysms, as well 
as from the danger of its giving rise to puerperal thrombus and pyemia, exhaus- 
tion, and a protracted convalescence. It is very certain, he however admits, 
that a cautious selection of single cases may be made, in which a single bleeding 
may not be inadmissible — cases occurring in strong, full-blooded patients, with 
violent pulsation of the carotids, with a dark red hue of the face remaining for 
some time after the paroxysm, and with indications of commencing oedema of 
the lungs, there being, at the same time, entire absence of any signs of anaemia, 
chlorosis, or debility. 

If the eclampsia continue or first occur after delivery, and the chloroform and 
acids do not act with sufficient promptness and permanency, Prof. B. recom- 
mends large doses of opium or acetate of morphia, from one to six grains of the 
first, or from a quarter of a grain to a grain of the latter, every six hours, and 
at the same time an enema of from twenty to thirty drops of anodyne tincture. 
With respect to the value of opium as a remedy in such cases, the observations 
of Kiwisch, Scanzoni, Kilian, Wieger, Hohl, Feist, Gede, and others, correspond 
with those of the author. 

For the removal of the coma remaining after the cessation of the convulsive 
paroxysm, the remedies recommended are complete rest of body, mind, and ex- 
ternal senses — with perfect quietness — the use of benzoic and vegetable acids, 
cold drinks, and moderate diaphoresis. The author is opposed to all derivatives 
— as sinapisms, blisters, local hot bathing, etc. Hasse advises an active impres- 
sion to be made upon the bowels by calomel or castor oil, by the mouth, or 
enemata of assafoetida and vinegar, infusion of senna, croton oil, and the like. 

During the convulsive paroxysm, the patient is to be guarded from injury, 
and from wounding her tongue, by proper restraint — which should not, however, 
confine the extremities, or embarrass the freedom of their movements. 

When eclampsia occurs in connection with labour, if the expulsion of the child 
is not speedily accomplished, the author advises the acceleration of delivery by 
the rupture of the membranes, and the mechanical dilatation of the vagina and 
OS uteri, the free scarification or division of the latter, or, where all things are 
favourable to their use, by the application of the forceps, or by such other mea^- 
sures as the nature of the presentation and the character of the labour warrant. 

When, after the birth of the child, the discharge of urine is delayed, or only 
a very small amount is voided, the catheter should be introduced, in order to 
avert the retention and decomposition of the urine in the bladder, and the dan- 
ger of resorption of carbonate of ammonia. 

For the details of treatment we must refer to the work itself. In cases of 
eclampsia occurring during the pregnant, parturient, or puerperal condition of 
a female, where the cause of the convulsions can be traced with tolerable cer- 
tainty to ursemic intoxication — and this can only be done when we ascertain that 
the urine is rich in albumen and cylindrical clots, and deficient in uric acid and 
urea — there can be little doubt that the treatment laid down by Prof. B. is, in 
its general outlines, the one best adapted to conduct the case to a favourable 
termination. From the induction of asthenia in cases of puerperal convulsions, 
we have repeatedly experienced the best results, and the opium practice has in 
its favour the testimony of some of the most authoritative of the practitioners of 
the continent of Europe. Notwithstanding the unqualified denunciation of gene- 
ral bloodletting in true puerperal eclampsia by the author, we must insist upon 
its propriety, it' not as a curative, which it can seldom be considered, at least as 
a precautionary means, by w^hich the brain and other organs are placed in a con- 
dition better adapted to sustain without injury the violent convulsive paroxysms. 
We admit that bleeding has heretofore been carried to an unwarrantable extent 
in all the forms of puerperal convulsions, but this abuse of the remedy is no 
argument against its judicious use in the cases to which it is appropriate. There 
No. LXXIIL— Jan. 1859. 15 



222 



Bibliographical Notice 



[Jan. 



is certainly no remedy that lias been proposed in the treatment of eclampsia 
puerperalis that has in its favour a greater array of imposing authority. 

To relieve the uterus of its contents as speedily as possible, when the convul- 
sions occur during labour, is no doubt advisable ; we cannot, however, be brought 
to believe that the necessity for this is so urgent as to warrant, in order to effect 
it, a resort to manipulations, which can be justified only under circumstances 
where a neglect of them would very certainly endanger the life of both mother 
and child, which circumstances certainly do not present themselves in any of the 
ordinary forms of puerperal eclampsia. D. F. C. 



Art. XXXYI. — A System of Human Anatomy, General and Special. By 
Erasmus Wilson, F. R. S., author of "The Dissector's Manual," "A Treatise 
on Diseases of the Skin," etc. etc. A new and improved American, from an 
enlarged London edition. Edited by William H. Gobrecht, M. D., Professor 
of Anatomy in the Philadelphia College of Medicine, Fellow of the College of 
Physicians of Philadelphia, etc. With three hundred and ninety-seven illus- 
trations on wood. Philadelphia : Blanchard & Lea, 1858. 8vo. pp. 616. 

Of the many treatises on anatomy which we possess there is, perhaps, none 
more favourably known to the profession than the work with the foregoing title. 
In this country a copy of Wilson's Anatomy is found on the shelves of nearly 
every practitioner and in the hands of nearly every student of medicine, a fact 
which of itself sufficiently proclaims the high estimation in which the volume is 
held by American medical men. Of the merits of the work generally we need 
therefore say nothing ; but we cannot refrain on the present occasion from re- 
marking that this new edition is by far the most perfect of any which have ever 
appeared. The volume, in passing for the seventh time through the English press, 
has undergone a most careful revision at the hands of the author ; many portions 
of it have been entirely rewritten, especially the introductory chapters relating to 
histological anatomy. 

Yery many valuable annotations, additions, and illustrations have also been 
introduced by the American editor. Dr. Gobrecht. In our opinion the merits of 
the work have been much increased by the evident labour and assiduity expended 
by Dr. Gobrecht in his endeavours to render the present volume a manual of ana- 
tomy of the most sterling character. The duties of the publishers have also been 
discharged in a most satisfactory manner ; and we feel confident that this new 
edition of so valuable a book cannot but meet with the same degree of favour 
which has always characterized the appearance of its predecessors. J. H. B. 



1859.] 



223 



aUARTERLY SUMMARY 

OF THE 

IMPEOYEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. Results of an extended Inquiry into the Quantity of Carbonic Acid evolved 
from the Lungs under the Influence of various Agents. — Dr. Edward Smith, in 
a communication to the Section of Physiology of the British Association for the 
Advancement of Science, stated that he had conducted a series of experiments 
extending over several months, and found, by his new instrument, that the quan- 
tity of carbonic acid expired varied most materially under the influence of dif- 
ferent kinds of food, different states of the atmosphere, etc. The paper went 
into an inquiry — first, as to the quantity of carbonic acid expired in twenty-four 
hours, with the variations hour by hour; second, the influence of season; and 
third, the influence of nearly all ordinary articles of food and of a few medicines. 
During the summer, respiration is always feeble, as compared with the colder 
months of the year ; and although the skin exercised most important functions, 
he found that it was not vicarious for the lungs in the expiration of carbonic 
acid; for while the lungs expired 600 grains, the skin threw off only six grains. 
The increase in the quantity of carbonic acid was greater and more enduring- 
after eating ^oatmeal and rice than after partaking of arrowroot ; whilst wheat 
produced the greatest quantity, though the increase was less enduring than with 
oatmeal and rice. Tea, coffee, and cocoa were found to be respiratory exciters, 
and consequently increased the waste of the system ; they could not be classed as 
food ; but as tea induced perspiration, it was most valuable as a remedy against 
the action of heat. Tea caused the evolution of much more carbon than it sup- 
plied. Tea would also be useful in cases of drowning and interrupted pulsation. 
Brandy, sometimes administered in cases of drowning, had the very opposite effect 
to that desired, being a non-exciter of pulsation ; whereas tea increased the action 
of the lungs and skin. If the object were to prevent the waste of the system, 
then alcohol might be useful, and tea would be improper ; but if they wished to 
refresh themselves, tea should be taken. The experiments made showed that 
those who were more susceptible of injurious influence by heat were the least able 
to bear any change of climate ; and if this were borne in mind, it would be found 
of service to those who might contemplate going abroad — to the East or else- 
where. — British Medical Journal, Oct. 23, 1858. 

2. Experiments on Digestion. — Dr. Geo. Harley read a communication on 
this subject before the Section of Physiology of the British Association for the 
Advancement of Science, at its late meeting in Leeds. 

The communication was illustrated by numerous experiments showing the pro- 
perties of the saliva, the gastric juice, the bile, and the pancreatic secretion. 
The author stated that, contrary to an opinion lately published by Bernard, he 
had found that the human saliva contains both sulphocyanide of potassium and 



224 



Progress or the Medical Sciences. 



[Jan. 



iron. The latter substance, however, can only be detected after the organic 
matters contained in the secretion are destroyed by burning. Dr. Harley had 
ascertained that a person of nine stone secreted between one and two pounds of 
saliva in twenty-four hours. The gastric juice, the author said, does not destroy 
the power possessed by the saliva of transforming starch into sugar; conse- 
quently, the digestion of amylaceous food is continued in the stomach. The 
gastric juice has the property of changing cane into grape sugar. The author 
made some remarks upon the cause of the gastric juice not digesting the living 
stomach ; and said that his experiments showed that it is not the epithelium 
lining the organ which prevents its being digested, but the layer of thick mucus 
which covers its walls. When the latter substance is absent, the gastric juice 
attacks the walls of the living stomach, and digests them, causing perforation 
and death. As regards the bile, it seems that this secretion takes an active part 
in rendering the fatty matters of our food capable of being absorbed into the 
system. The most curious of all the digestive fluids, however, is the pancreatic 
secretion, for it unites in itself the properties of all the others. It not only 
transforms starch and other such substances into sugar, but it emulsionizes fats, 
and even digests protein compounds. As a remedy in indigestion, pancreatine 
should be greatly superior to pepsine, which can only digest one kind of food, 
namely, protein. The author said he had been labouring to obtain pancreatine 
in a perfectly pure state, and had been to a certain degree successful. With 
pancreatine, we should be able to digest any kind of food we pleased ; and, there- 
fore, the obtaining of it in a state of purity would prove an invaluable boon to 
suffering humanity. — British Med. Journ., Oct. 16, 1858. 

3. On the Form of the Eyeball, and the Relative Position of the Entrance of 
the Optic Nerve in different Animals. — Mr. Thos. Nunnelby read an interesting 
jjaper on these subjects before the British Association for the Advancement of 
Science, at its recent meeting at Leeds. 

It was well known, he observed, that the orbits are much larger than the eye- 
balls, and that their axes diverge considerably in an outward direction, while 
those of the two eyes are perfectly parallel. The eyeballs lie in the fore-part of 
the orbits, and, according as they are more or less prominent, and more or less 
covered with the lids, do they appear to be larger or smaller. The eye of the 
infant is larger, in proportion to the size of the body, than that of the adult ; but 
it is by no means certain that the eye of the male is larger, proportionately to 
the size of the body, than the eye of the female. By some anatomists, the human 
eye was described as a spheroid, the diameter of which, from before to behind, 
is greater than in any other direction. He had measured a greai number of 
eyes, of the human subject as well as of animals, and he found that wherever 
there was a departure from the spherical figure, it was in a direction contrary to 
that which had been commonly stated. In some instances, the difference be- 
tween the two diameters was scarcely perceptible ; in all where a distinction was 
observed, the transverse was the greatest. He had prepared a set of tables, 
which were printed, containing the result of the measurement of two hundred 
eyes of various creatures. The measurements, he thought, clearly proved that, 
whatever part the fibres of the optic nerve play in the phenomena of vision, the 
greatest number of them are distributed on that part of the eyeball where there 
is the greatest range of vision, and that the greatest expanse of retina is on that 
part of the ball opposite to where objects are placed, and, consequently, it is 
where the visual image of them must fall. That this was a fact, a careful com- 
parison of the position of the eyes in the head, the size of the eyeball, and the 
exact position of the entrance of the nerve into it, with the mode of life and 
habits of various creatures would render obvious. Man, from the erect position 
of his body, the horizontal placing of his eyes, and his habits, has a more panoptic 
range than any other creatures (of course, in this consideration, all motions of the 
head, neck, and body of the animal must be excluded, and those of the eyeballs 
alone admitted). In him, the optic nerve enters the ball not far from the centre, 
leaving, however, a somewhat shorter space on the inner and lower parts of the 
retina than on the upper and outer. Now, while man enjoys a free range of 
vision above the horizontal line, there are far more occasions for him to look 



1859.] 



Anatomy and Physiology. 



225 



at objects below than above this line; and thus more visual images are projected 
to the upper and outer sides of the entrance of the optic nerve than to the inner 
and lower sides of this spot. In the pig", who sees at no great range before him, 
and who seeks his food with the snout almost always on the ground, whose head 
and eyes are consequently, for the most part, downwards and near to the ground, 
the nerve enters the ball more outwardly, and much lower, than it does in man. 
The pig wants not to see far before him, but he does require, while grubbing, to 
look behind him from whence danger comes. So with the timid herbivorous 
animals. In the bullock and sheep, who pass much time with the head in a 
dependent position, near to the ground, in open plains, the upper and inner sides 
of the retina are much larger than the lower and outer portions ; while in the 
deer, who live in more wooded places, where danger is from the front, but who, 
like the bullock, has the head downwards in feeding, though the inner or anterior 
side of the retina is still larger than the posterior, it is so to a much less extent 
than it is in the bullock, while the upper portion still continues as proportionally 
large as it is in sheep and bullocks. On the contrary, in the horse, who is not 
preyed upon, who carries the head erect, and observes all around, the nerve 
enters the eye more nearly in the axis. In birds, with few exceptions, the upper 
portion of the retina is much more considerable than the lower parts ; but the 
anterior and posterior portions vary much in different genera. Those whose 
locomotion is performed principally by the feet, and whose range of habitation 
is very small — as the common fowl and turkey — have the inner or anterior por- 
tion very considerably greater than the outer or posterior. Those birds whose 
range is greater, and who use the wings for progression, but do not wander very 
far — as the grouse and partridge — have a much less difference in the two por- 
tions of the retina ; while in those birds whose flight is far and prolonged — as 
the crow, rook, swan, goose, and duck — the entrance of the nerve is very nearly 
in the centre of the ball. So in reptiles : in the turtle, who only requires to see 
immediately before and under him, the outer and upper portion of the retina are 
very much the larger. In the more active alligator, frog, toad, and chameleon, 
while the upper portion maintains its size, the outer and inner parts are more 
nearly equal. In those creatures whose habitation is, for the most part, under 
ground — as the shrew and the mole — the eyes are so small as to have led Ma- 
gendie to assert that the mole is without the organs altogether ; but this is not 
the fact, for all the essentials of an eye exist, even true retinal elements, optical 
nerve, and a well-developed choroid ; yet the organ is so minute, and concealed 
by the skin and hair, as probably only to enable the creature to discern the light, 
which is all that it requires ; for, living under ground, where it seeks its prey, it 
obviously must depend on the acuteness of other senses, rather than of sight, for 
its living. Though in the individual there is usually some proportion between 
the size of the eye and the body, taking different classes and genera, the size of 
the animal is very little guide to that of the eye, the proportions between the 
two being determined by other considerations than that of the bulk alone of the 
creature ; for though, as a whole, the eye in fish bears a larger proportion to 
the whole body than it does in other divisions of the animal kingdom, and the 
eyes of birds are, as a class, much larger than those of mammalia or reptiles, 
yet amongst the different genera of all these classes, there are very great differ- 
ences, determined, apparently, by the following considerations, amongst others 
not so obvious : When the creature lives in feeble light, yet moves actively about, 
and is guided in its locomotion by the sense of sight — as in nocturnal birds and 
animals, and fish — the eye is very large, apparently to take in a large quantity 
of the feeble light; on the contrary, where the creature is guided in its move- 
ments by other senses, then the eye is very small — as in the bat, the mole, the 
shrew, and the eel. Where vision penetrates to a long distance, and where the 
eye enjoys great power of overcoming the aberration of the parallax, the eye is 
large — as in rapacious birds. When the brain and intellect are more developed, 
the size of the eye diminishes, and the two eyes become more parallel — as in man 
and the higher mammalia. Where animals are feeble, timid, have but little de- 
fensive power, and are preyed upon, the eye is usually very large — as in the hare, 
the conies, the whole deer tribe, and many other of the ruminants. Where the 
animal is not predaceous, and its size and strength are such as to protect it from 



226 



Progress of the Medical Sciences. 



[Jan. 



being preyed upon, the eyes are commonly small — as in the whale and the ele- 
phant. In the latter, the eye is even smaller than it is in the horse, and scarcely 
larger than in the eagle. — British Med. Journal. 

4. The Structure of the Choroid Coat of the Eye, and more particularly the 
Character and Arrangement of the Pigmentary Matter. — Mr. Thos. Nunneley 
read a paper on this subject, before the Physiological Section of the British 
Association, at its meeting in Leeds. The choroid coat is the dark tissue inter- 
posed between the delicate sentient retina and the hard, dense, sclerotic, and 
co-extensive with the latter. It begins at the entrance of the optic nerve by a 
round aperture, with a distinct edge, in close apposition with the nerve, but not 
organically connected with it, and passing forward as far as the junction of the 
sclerotic and cornea, where, as choroid proper, it terminates. It there comes in 
connection with the ciliary circle or muscle, the ciliary body and the iris. The 
choroid is essentially a vascular membrane, being made up of bloodvessels, 
colouring matter, and a modified white fibrous tissue. The choroid universally 
provided the pigmentum nigrum, and is of a deep bronze colour, approaching to 
lilack. The pigment was described as consisting of two distinct forms of cells — 
on the inner surface the choroid, of true hexagonal cells, and in the tissue, and 
on the posterior surface, of stellate cells. The use of these cells was to destroy 
the light as soon as it had acted on the retina ; and they were the most perfect 
absorbers of light of any substance in nature that Mr. Nunneley knew of. From 
the account he gave of the arrangement of the pigment, it afforded what he con- 
sidered a satisfactory anatomical explanation of an abnormal condition of the 
eye which had hitherto not been understood — muscce volitantes. The figures of 
those motes he believed to resemble exactly portions of the choroid coat when 
teazed out; and they might be expected to appear and disappear with the vary- 
ing condition of the vessels arising from disordered stomach, or the cerebral cir- 
culation, and be cured by whatever corrects those conditions ; or the muscae 
might result from different organic changes in the choroid coat, which are inca- 
pable of being removed. — British Med. Journ., Oct. 9, 1858. 



MATEEIA MEDICA AND PHAKMACY. 

5. New Modes of Administering Iodine. — Efforts have lately been made in 
France to administer iodine in a more efficacious manner than had hitherto been 
done. M. Leriche, of Lyons, has published valuable articles in Z/' Union M^di- 
cale, wherein he endeavours to show that iodine, combined with vegetable sub- 
stances, advantageously replaces cod-liver oil. He proposes a syrup made of the 
juice of water-cress and iodine, and also an iodine wine. The syrup has the 
advantage of not fermenting, and contains exactly one grain of iodine per ounce. 
The wine is composed thus : Bordeaux wine eight ounces ; concentrated infusion 
of red roses about thirteen drachms ; tincture of iodine one drachm and a half. 
Each ounce contains one grain of iodine. From one to six tablespoonfuls may 
be given daily, according to the indications and the age of patients. In the space 
of three years M. Leriche treated 38 scrofulous patients with the wine ; 21 were 
perfectly cured after a treatment steadily pursued for some time ; 8 did not im- 
prove at all; and 9 improved but slightly, either because the treatment was 
carried on imperfectly, or because it was left off too soon. 

M. BoixET, on the other hand, well known by long-continued investigations 
respecting the use of iodine, read, on the 28th of September last, before the 
Academy of Medicine of Paris, a paper, in which he proposes to use iodine as 
an article of food. The author administers iodine as found in nature, viz., com- 
bined with those plants which contain the greatest quantity of the alkaloid. The 
latter being thus given in minute doses, in a continuous and almost imperceptible 
manner, yields most advantageous results. M. Boinet uses fuci, marine plants, 
cruciferse, salts containing iodine, and some mineral waters holding iodine in 



1859.] 



Materia Medica and Pharmacy. 



227 



solution. His excipicnts are ordinary bread, ginger-bread, cakes, biscuits, cho- 
colate, wine, beer, syrups, &c., some being especially calculated for children. 
Trials were begun by M. Boinet as far back as 1849, upon subjects suffering very 
severely from the various well-known scrofulous symptoms, and most of them 
were cured after continuing the iodized food for several months. The author has 
not found that iodine administered for a long time produced a loss of flesh and 
atrophy of certain organs. Far from having these effects, the iodine, in his hands, 
has invigorated patients, and favoured the development of organs. Messrs. Cha- 
tin and Trousseau are to report upon the paper. 

6. TJierapeutzc Properties of SarsapartUa. — Dr. A. M. Adam, in speaking 
of Prof. BocKER, of Bonn ("'Medical Notes from the Continent," &c., in Edin- 
hurgh Med. Journ., Oct. 1858), states his most recent pharmaco-dynamic experi- 
ments, " which, I believe, are as yet unpublished, have been made with sarsaparilla. 
He informed me that, after carefully performing ninety-eight experiments with 
this drug on healthy people, he found that, contrary to all our usually received 
opinions on the subject, it possesses neither diuretic nor diaphoretic properties. 
Another series of twenty-six experiments, on the persons of uncured syphilitic 
patients, gave exactly the same results. Bocker also satisfied himself that sarza 
does not increase the efficacy of the agents, such as iod. potass., etc., which are 
usually given along with it ; and that the good results obtained by the adminis- 
tration of this salt, dissolved in decoction of sarza, are in no degree attributable 
to any virtue in the solvent fluid. I told Dr. Bocker that I remembered hearing 
Professor Syme, many years ago, express his opinion on the utter uselessness of 
so expensive a drug as sarza, remarking, in his own quaint, forcible style, that 
he believed an "infusion of hay " would be just as good, and a vast deal cheaper. 
He seemed amused, and said that he entirely agreed with Syme ; that infusion 
of sarza had no greater effect on the system than so much common tea ; and 
that we must regard it merely as a pleasant, but very expensive, vehicle for the 
administration of other medicines." 

[Our own clinical observations have led us to the same conclusions as have 
been arrived at by the learned professor of Bonn, as to the utter absence of any 
therapeutic properties in the sarsaparilla.] 

7. Formula for Jaser's Itch Ointment. — Of all the ointments proposed for 
the treatment of scabies, one of the most efficacious, and at the same time least 
expensive for charitable institutions, is that of Jaser. Dr. Delaharpe, Physician 
to the Hospital at Lausanne, has used it for many years, with invariable success. 
The following is the formula : — 

Flowers of sulphur, half an ounce ; sulphate of zinc, one and a half drachms ; 
powdered root of white hellebore, one drachm ; soft soap, thirteen drachms ; 
hog's lard, two ounces. M. Delaharpe has been for some years in the habit of 
adding half a drachm of essence of caraway. The latter addition has percepti- 
bly increased the activity of the ointment, without rendering it more irritating. 
A pound of the preparation costs about two shillings. Each patient requires 
for cure, on an average, 'about eight ounces. 

Would it be possible, asks Dr. Delaharpe, to diminish the number of substances 
entering into the composition of the ointment, without impairing its antipsoric 
properties ? I fear not. The fat and the potash soap modify one another, and 
by increasing the proportion of soap, we should run the risk of having too irri- 
tating an ointment. I propose, however, to make some experiments on this 
point. The sulphate of zinc does not here act a corrosive part, as might be 
supposed, for it is completely decomposed by the potash of the soap ; it thus 
serves to form a little sulphate of potash, and by degrees some sulphuret of zinc, 
by contact with the sulphur. The sulphuret of zinc may have an antipsoric 
action, at the same time that it contributes to diminish the itching and irritation 
of the skin, as zinc ointments in general do. A little hydro-sulphuric acid, which 
is disengaged from the sulphuret of zinc, may also favour the action of the 
ointment. 

The powdered hellebore and essence of caraway are the most active antipsoric 



228 



Progress of the Medical Sciences. 



[Jan. 



elements of the compound ; their quantities could not be diminished without dis- 
advantage — I should rather endeavour to augment them ; but perhaps we should 
have to dread a general action, in consequence of the absorption of veratria. 

Further, we must not forget that the most essential condition in the treatment 
consists in the administration of a soap-bath on the admission of the patient. If 
soft soap of good quality be employed, and if the patient takes care to brush or 
rub his skin strongly in the bath, the cure is effected in twenty-fOur hours. The 
want of these precautions, I have more than once observed, is sufficient to delay 
the cure by a day at least. This explains a fact which has often surprised me — 
the greater obstinacy of the itch in females, notwithstanding the usually greater 
delicacy of their skin. Through modesty or want of management they do not 
rub themselves sufficiently in the bath, and the action of the ointment is re- 
tarded. — Dub. Hos'p. Gaz., Nov. 15, 1858, from Bull. Gin. de Thirap., 15th 
June, 1858. 

8. Glycerole de G our don and Oil of Cade, as a topical application in Ecze- 
matous and Impetiginous Eruptions. — Modern observers have classed resinous 
and empyreumatic substances, so extensively employed by the ancients, among 
the most powerful local applications in the treatment of herpetic eruptions. 
Thus, purified tar, mixed with lard, in the proportion of from fifteen to forty-six 
grains of the former to an ounce of the latter, is daily used in the wards of the 
H6pital St. Louis, as the resolvent, par excellence, of scaly eruptions, and as a 
valuable desiccative in chronic, eczematous, and impetiginous affections. Since 
the introduction of glycerine into therapeutics, M. Gibert employs this substance 
as an excipient, in preference to lard. To facilitate its use, the mixture is thick- 
ened by the addition of starch, according to M. Garot's process. This prepara- 
tion possesses the advantage over ordinary ointments made with a fatty excipient, 
that it is removable by water. 

The following is the formula of the gJycSrole de goudron: Glycerine, one 
ounce ; purified tar, half a drachm ; add, with the aid of heat, powdered starch, 
half an ounce. With this quantity of starch, which has been determined by M. 
Lecocq, we obtain an ointment of thin consistence, and easily spread. The mix- 
ture should be perfectly homogeneous. 

This application allays itching (we have seen it rapidly succeed in cases which 
had for several years resisted various and numerous remedies) ; it dries up ex- 
coriations, checks exhalation, dissipates slight cutaneous phlegmasise ; it acts, in 
a word, as an astringent and resolvent, without producing irritation. Thus, 
eczema rubrum, impetigo, intertrigo, prurigo of the scrotum and anus, acne 
rosacea, and sub-inflammatory mentagra, are, under its influence, most advan- 
tageously modified. 

Another product very well known to the readers of this journal is the huile de 
cade (oil of pitch). M. Gibert uses it very frequently; but as the empyreumatic 
properties which this resinous oil possesses in a much higher degree than tar, 
are such, that it can seldom be applied in a state of purity, he usually mixes it 
with oil of sweet almonds, or with cod-liver oil. The following preparation is 
used, under the name of huile cadie, in the Hopital Saint Louis : Cod-liver oil, 
two parts ; oil of pitch, one part. This application possesses very efficacious 
resolvent and drying properties. M. Gibert has seen eczemas, which had con- 
tinued for months in a stationary, red, excoriated, and oozing condition, notwith- 
standing the external and internal use of preparations of sulphur, heal under the 
influence of this combination. 

It is particularly in cases of obstinate pruriginous, papulous, and eczematous 
eruptions of the anus and genitals, which are so often such a source of annoyance 
to both the patient and the practitioner, that M. Gibert has most frequently 
derived benefit from the local use of oil of pitch. He adds, in such cases, the 
diligent use of cold hip-baths, and, in order to alter the diathesis on which the 
eruption depends, the internal employment of Dr. Boudin's arsenical liquor, mo- 
dified in the following manner : Distilled water, one pint ; arsenious acid, three- 
quarters of a grain ; dissolve with the aid of heat. The mixture is divided into 
six vials, each of which is marked for two days ; half a bottle to be taken for a 



1859.] Medical Pathology and Therapeutics. 



229 



dose each morning, fasting, with the addition, at the moment the medicine is 
swallowed, of a cup of chicory, sweetened with honey. M. Gibert states that he 
has seen eruptions of several years' standing, and which had resisted the use of 
thermal waters, and of many other remedies, yield in a few weeks to this mode of 
treatment. — Dub. IIosp. Gaz., Nov. 15, from Bull G6n. de Th^rap., 15th Aug., 
1858. 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

9. On the Nomenclature and Classification of Continued Fevers. — Dr. Chas. 
MuRCHisoN, in an interesting paper {Ed. Med. Journ., Oct. 1858), of which this 
is the title, remarks that all the divisions of continued fevers have, for the most 
part, been founded upon their symptoms, or their supposed anatomical origin, 
but that he is convinced that the most philosophic classification must be one 
based on their etiology. Dr. M. maintains that the class of continued fevers 
comprises three, or, in all probability, four, distinct species, originating from 
widely different causes. 

" First, there is typlius, the grand predisposing cause to which is destitution ; 
while the exciting cause, or specific poison, is generated by overcrowding of 
human beings, with deficient ventilation, and afterwards is propagated by con- 
tagion. Hence it is, that epidemics of typhus occur during seasons of famine, 
and in besieged cities ; and hence it is, that we find it limited to the most over- 
crowded localities of large towns, and seldom meet with it in country districts, 
or in the upper classes of society. 

" Secondly, there is the ' relapsing fever' about which there may still be some 
doubts as to its specific distinction from typhus. There can be no question that 
it differs widely from that disease, both in its symptoms and mortality; and also, 
that a previous attack of the one confers no immunity from a subsequent one of 
the other. On the other hand, relapsing fever is found to prevail, as epidemics, 
at the same times, and under the same circumstances, as typhus. Researches 
are still wanting as to the distinctive etiology of these two fevers ; but I have 
grounds for believing that it will yet be shown that relapsive fever is produced 
by famine alone ; typhus by destitution and overcrowding combined ; in other 
words, that destitution and starvation are the predisposing causes of typhus, the 
exciting causes of relapsing fever. 

" Thirdly, there is typhoid or enteric fever, which is less contagious than either 
typhus or relapsing fever, and which is quite independent of the causes which 
give rise to these, being generated by the putrid emanations from decaying 
organic (animal) matter. The grounds for this opinion may be briefly summed 
up as follows : — 

"1. Previous attacks of either typhus or relapsing fever confer no immunity 
from subsequent attacks of typhoid fever (and vice versa) . 

"2. There is no authenticated proof that the poison of typhus has ever gene- 
rated typhoid fever (nor vice versa) . 

"3. Typhoid fever does not prevail in wide-spread epidemics. It is essen- 
tially an endemic disease ; or when it does become epidemic, such epidemics are 
always of the most limited and circumscribed character. 

"4. Typhoid fever is always most prevalent in autumn, or after along con- 
tinuance of hot weather. A hot autumn, after a wet summer, appears to afford 
the most favourable conditions for its development. 

" 5. Typhoid fever is not, like typhus and relapsing, limited to the poor, but 
is met with among poor and rich alike. 

" 6. Typhoid fever is not confined to overcrowded localities, but appears alike 
in the most dense and in the least populous districts of large towns, and even in 
isolated houses in the country. 

7. There is evidence, of the most conclusive nature, that typhoid fever may 
result from the emanations from (animal) organic matter, in a peculiar state of 



230 



Progress or the Medical Sciences. 



[Jan. 



decomposition.'* In every instance where 'fever' has been described as originat- 
ing from sucli a cause, the fever has been typhoid. The reason why this cause 
is not more generally recognized, is the want of attention to the distinctions be- 
tween the different fevers. Those who deny that ' fever ' can be the result of 
putrid emanations, adduce thousands of cases of typhus and relapsing fever as 
negative evidence, in the same way as there are not wanting a few who bring 
forward typhoid cases to prove that fever cannot be the result of destitution and 
overcrowding. 

" Fourthly, there is simple fever, or fehricula, which is non-contagious, and 
arises from such non-specific causes as exposure to the sun's rays, fatigue, sur- 
feit, etc. In its simplest form, this fever may terminate in twenty-four or thirty 
hours, as in the ephemeral or diary fever of systematic writers, or it may be 
prolonged to eight or ten days, as in the ardent or sun fever of tropical climates." 

All the continued fevers which have been described by authors under so many 
names, may be referred, according to Dr. M., to one or other of the four species 
already spoken of. Dr. M. has arranged the following synonyms under each of 
the fevers to which he believes they belong. He likewise gives briefly the leading 
distinctive characters of each fever. 

I. Typhus Fevee. 

Cliaraders. — A disease generated by contagion, or by overcrowding of human 
beings, with deficient ventilation, and prevailing in an epidemic form in periods, 
or under circumstances of famine and destitution. Its symptoms are : more or 
less sudden invasion marked by rigors or chilliness ; a small, weak, usually fre- 
quent pulse ; dry, brown tongue ; in most cases, constipation ; skin warm and 
dry ; a morbilliform rash, appearing between the fifth and eighth days, frequently 
accompanied by true petechiae, and lasting until death or recovery ; great and 
early prostration ; delirium coming on early, and for the most part low and wan- 
dering ; contracted pupils ; duration of the fever usually about 14 days, seldom or 
never more than 21. In the dead body, no specific lesion, but great congestion 
of all the internal organs. 

Synonyms. 

Td(|)oj (Hippoc. ?) Febris typhodes? {Prosp. Alpin., 1611; Recalchus, 1636; 
Juncker, 1718); Typhus [Cullen, 1769); Enecia Typhus [Mason Good, 
1817); Typhus and True Typhus [modern English loriters). 

Febris pestilens [Galen f Fracastorius, 1546; Forestus, 1591; Riverius, 1623; 
Willis, 1659; Sydenham, 1668); Febris epidemica [J. Burserius, 1625); 
Pestilential Fever [Grant, 1775; Stoker, 1826); La constitution epidemique 
[Beaulac, 1810) ; Epidemic Fever pro parte [recent writers). 

One of the morbi contagiosi (of Fracastor., 1546) ; Febris contagiosa [Coytterus, 
1578); Infectious Fever [Lind, 1763); Der ansteckende Typhus) J. V. Hil- 
denhrand, 1810); Typhus contagieux [J. C. Gasc, 1811); Das ansteckende 
Nervenfieber [Horn, 1814); Contagious Fever [Bateman, 1818); Tifo con- 
tagioso [Rossi, 1819); Contagious Typhus [English writers). 

Febris putrida et maligna, Synochus putris and S. cum putredine [old authors) ;3 
FelDris maligna pestilens (jKwerms, 1623 ; Sennertus, 1641; Willis, 1659); 
Malignant Fever [Langrish, 1735 ; Fordyce, 1791) ; Febris continua prutrida 
[Boerhave, 1738; Wintringham, 1752); Putrid Malignant Fever [Huxham, 
1730) ; FelDris exanthematica, maligna, et venenosa, et perniciosa [J. F. 
Bianchini, 1750); Febris maligna [Le Roy, 1771); Putrid Fever [Mac- 
bride, 1772) ; Febris continens putrida [Selle, 1770); Das Faulfieber [Hecker, 

' In addition to the evidence upon this point which will be found in my essay in 
the Medico- Chirurgical Transactions, I may allude to the circumstance, that Dr. 
Barker, of Bedford, has recently succeeded in producing in animals symptoms very 
similar to those of typhoid fever, by making them inhale the noxious principles 
arising from cesspools. — The Influence of Sewer Emanations, by T. Herbert Barker, 
M. D. London, 1858. 

2 Probably a different disease. 

3 Previous to the time of Huxham and Pringle, the terms putrid and malignant 
were frequently applied to all fevers, except the simple or febricula. 



1859.] Medical Pathology and Therapeutics. 231 



1809); Febbre putrida [Tl.al.); Fi^jvres putrides et malig'nes, pro parte 
[Fr.) ; Typhoid Fever, with putro-adynamic character ( Copland, 1844). 

Febris contagiosa in carceribus genita [Huxham, 1742); Jail Fever {Pringle, 
1750; Heysham, 1782 ; John Howard, 1784); Typhus Carcerum {i^auvages, 
1764) ; Febris carceraria [Burserius, 1785) ; Jail distemper [J. C. Smyth, 
1795); Maladie des Prisons {Fr.). 

Malignant Fever of the Hospital {Pringle, 1152) ; Febris nosocomialis {Burse- 
rius, 1785); Fifevre des Hopitaux {Fr.). 

Pestis bellica and Typhus bellicus {var.); Morbus Castrensis vel Morbus Hun- 
garicus, pro parte {many old authors) ; Morbus qui ex castris in Bavariam 
penetravit? {Rhumelius, 1624); Febris Castrensis {Willis, 1659; Haller, 
1742); Febris militaris {Petri, 1665); Typhus Castrensis {Sauvages, 1768); 
Camp Fever {Grant, 1775); Die Kriegspest {Huf eland, 1814); Typhus des 
camps et des armees {Louis, 1829). 

Febris pestilentialis nautica {Huxham, 1752); Ship Fever {Ltnd, 1763; Grant, 
1775); Febris nautica {Burserius, 1785). 

Febris pestilens quam Cuticulas vel Puncticula vocant {Fracast, 1546 ; Forest, 
1591); Tabardillo et Puntos? {Be Torres, 1574); Febris purpurea epi- 
demica? {Theroeus, 1578); Febris petechialis {Salius Biversus, 1584; Sen- 
nert, 1641 ; Selle, 1770 ; Burserius, 1785) ; Febris peticularis {Roboretus, 
1591); Febris purpurata? {Riverius, 1623); Febris pulicaris seu puncti- 
cularis {Pet. A. Castro, 1650); Morbus puncticularis {Bonkers, 1686); 
Febris petechialis ver {Hoffmann, 1700); Das Fleckenfieber {Ettmuller, 
1726; Reuss, 1814); Spotted Fever {Strother, 1728); Morbus cum pete- 
chiis {Strack, 1786); Febbre petecchiale {I^ossi, 1802; Rasori, 1812); 
Morbo petecchiale (^cer^ 1811 ; Palloni, 1817); Typhus exanthematicus 
and Das exanthematische Nervenfieber {of German writers); Petechial 
Fever {Peebles, 1835); Petechial Typhus {var.). 

Febris asthenica? {var.) ; Febris attacta pro _par^e {Selle, 1770); Fi^vre ataxique 
pro parte {Pinel, 1798); Fifevre adynamique {Pinel, 1798; Roux, 1813); 
Adynamic Fever {Stoker, 1826; Burne, 1828); Brain Fever? {var.). 

II. Eelapsing Fever. 
Characters. — A contagious disease, which is apparently generated by desti- 
tution, and which is only met with in the epidemic form during seasons of 
scarcity and famine. Its symptoms are: a very abrupt invasion, marked by 
rigors or chilliness ; quick, full, and often incompressible pulse ; white tongue ; 
tenderness at the epigastrium ; vomiting, and often jaundice ; enlarged liver and 
spleen ; constipation ; skin very hot and dry ; no characteristic eruption ; high- 
coloured urine ; severe headache, and pains in the back and limbs ; restlessness, 
and rarely subacute delirium ; an abrupt cessation of all these symptoms about 
the fifth or seventh day ; after a complete apyretic interval (during which the 
patient may get up and walk about), an abrupt relapse on the fourteenth day 
from the first commencement, running a similar course to the first attack, and 
terminating on or about the third day of the relapse; mortality small, but 
occasionally death from sudden syncope ; after death, no specific lesion, but 
usually enlargement of liver and spleen. 

Synonyms. 

A five days' Fever with Relapses {Rutty, 1770); Short Fever, Five days' Fever, 
Seven days' Fever {var., 1843); Relapsing Fever {Paterson, Steele, etc., 
1847 ; Jenner, 1849). 

Fever of the New Constitution {O'Brien, 1828.) 

The Epidemic Fever {auct. var.) ; Epidemic Fever of Edinr., 1817 ( Welsh, 
1819); Epid. Fev. of Ireland pro par/Je {Barker and Cheyne, 1821); Scotch 
Epidemic of 1843 ( War dell, R. Cormack, Alison, Jackson, Henderson, 
Craigie, etc.)-, the Silesian Fever of 1847 {Brit, and For. Med. Ch. Rev., 
July, 1851). 

Epidemic Remittent Fever {Mackenzie, 1843), Gastric Fever with Remittent 
type {Craigie, 1843); G astro-hepatic Fever {Ritchie, 1855); has also been 
designated — Mild Yellow Fever, Bilious Relapsing Fever, Bilious Remittent 
Fever, Remitting Icteric Fever. 



232 



Progress of the Medical Sciences. 



[Jan. 



Irish Famine Fever {Stoker, 1826 ; and Dublm Journal, 1849) ; Die Hungerpest 

[GraevelVs Notizen, 1848). 
Dynamic or Inflammatory Fever [Stoker, 1826); Synoclia [CJiristison, 1840 and 

1858). 

Relapsing Fever, in all probadilifi/, constituted one of the varieties of the In- 
flammatory Fever, or Synocha, of the writers of last century ; in more recent 
times, on the other hand, it has not unfrequently been considered a variety of 
Typhus. 

III. Pythogenic Fever. 
Characters. — An endemic, slightly contagious disease, generated by putrefy- 
ing organic (animal) matter. Its symptoms are : an invasion often insidious, or 
marked by slight rigors, a sensation of chilliness, or profuse diarrhoea ; pulse 
usually frequent and soft, but variable in the same patient; tongue red and 
fissured, in a few days becoming dry and brownish ; in most cases, but not in- 
variably, increased splenic dulness, tympanitis, abdominal tenderness, gurgling 
in the iliac fossge, and diarrhoea, with or without melaena ; urine copious and 
pale ; skin warm, often with irregular sweats ; an eruption of rose-coloured 
papules, first appearing between the seventh and fourteenth days, and coming 
out in successive crops, each of which lasts two or three days ; very rarely 
petechiae ; frequently epistaxis ; prostration coming on late, and often slight ; 
delirium active or often absent ; dilated pupils ; the disease often protracted to 
the thirtieth day, and occasionally, though rarely, followed by a relapse of all 
the symptoms, including the eruption ; after death, ulceration of the solitary 
and aggregated glands of the ileum, and enlargement of mesenteric glands. 

Synonyms. 

Typhus mitior and Synochus |)ro parte [Cullen, 1769); Abdominal Typhus 
[Autenrieth, 1822, and German writers generally) ; Fever with affection of 
the abdomen {Alison, 1827); Fever with ulceration of the intestines {Bright, 

1829) ; Synochus and Typhus with abdominal affection {SoutJnvood Smith, 

1830) ; Fifevre Typhoide {Louis, 1829; Chomel, 1834); Typhoid Fever 
{Stewart, 1840; Bartlett, 184:1 ; Jenner, 1849); Mild Typhoid Fever (Cop- 
land, 1844); Enteric Typhus {Gliristison, 1850).i 

JIupsVoj y/^u.t-T'pcT'atos ? {Hippoc); Hemitritaeus ? Tritoeophyas ? and Triphodes? 
{auctor. antiq. var.); Febris semitertiana seu composita {Galen? Forestus, 
1591; Spigelius, 1624); Tritoeophya typhodes {Mangetus, 1695); Frigerari? 
{Sagar, 1776). 

Infantile Kemittent Fever {var.); Febris hectica verminosa {Vander Bosch, 

1769) ; Febris verminosa {Selle, 1770); Infantile Gastric Eemittent Fever 
{Locock, 1840) ; Infantile Hectic Fever and Worm Fever {var.). 

Febris non-pestilens ? {Forestus, 1591); Morbus Hungaricus and Febris Hun- 
garica pro parte {Auct. var. et Sennertus, 1641); Endemic Fever {var.); 
Autumnal or Fall Fever {Austin Flint, 1852 ; and in America generally). 

Febris putrida {Riverius, 1623); Febris putrida quae vulgo lenta appellatur 
{Willis, 1659); Febris putrida nervosa? {Wintringham, 1752); Febris pu- 
trida aut biliosa {Tissot, 1758); Febris a putredine orta {A. Tralliani quoted 
hy Burserius as Sny. for his Feb. gastric, ac. 1785). 

Febris lenta {Forestus, 1591; Willis, 1659; Linnceus, 1763; FogfeZ, 1764) ; Fe- 
bris hectica sive lues neurodes ( Willis, 1667); Slow Fever {Strother, 1716; 
Langrish, 1735); Nervous Fever {Gilchrist, 1734); Slow Nervous Fever 
{Huxham, 1739); Febris chronica? {Juncker, 1736); Febricula, or Little 
Fever, commonly called the Nervous or Hysteric Fever, the Fever on the 
Spirits, Vapours, etc. {Manningham, 1746); Febris atacta pi^o parte {Selle, 

1770) ; Febris lenta nervosa maligna {Burserius, 1785); Irregular low ner- 
vous Fever {Fordyce, 1791); FiWre ataxique pro parte, and F. adeno- 
meningee {Pinel, 1798); Nervenfieber? {Bischoff. 1814); Fievre nerveuse 
{Fr.); Common Continued Fever {Armstrong, 1816); Low Fever {var.). 

Febris petechizans vel Spuria {Hoffman, 1699). 

Febris biliosa {Galen? River. 1623; Siahl, 1700; Juncker, 1736); Bilious Fe- 



' Clinical Lectures, not published. 



1859.] Medical Pathology and Therapeutics. 



233 



ver [Pringle, 1750; Rutty, 1770); Febris biUosa putrida {Selle, 1770); 
Febbre biUosa [Benelli, 1775); Synochus biliosus {Sauvages, 1763); Febris 
cholerica? { Vogel, 1764); Bilio-gastric Fester {Copland, 1844); Gastro- 
bilious, and Bilious continued Fever {modern writers). 

Febris catarrhalis? {BocJcel, 1580; C^m^^se, 1676); Febris colliquativa ? {J. R. 
Fortis, 1668); Febris Stercoralis? {Quesnay, 1753); Morbus mucosus 
{Roederer and Wagler, 1762); Febbre glutinosa gastrica {Sarcone, 1765 J; 
Febris mucosa {Seile, 1770); Febris pituitosa {StoU, 1785); Strack, 1789); 
Febris colliquativa primaria seu essentialis {Burserius, 1785); Morbus 
biUosus mucosus {Knaus, 1786); Febris pituitosa nervosa {Jacobi, 1793); 
Schleimfieber ? {Canz, 1795); Fifevre muqueuse {Fr.), Mucous or Pituitous 
Fever (Cop/awd, 1844). 

Febris gastrica {Ballonius, 1734) ; Febris acuta stomachica aut intestinalis 
{Hetster, 1736); Febris gastrica acuta {Burser, 1785); Fi^vre meningo- 
gastrique {Pinel, 1798); Gastrisches Fieber {Rtchter, 1813); Fifevre gas- 
trique {Bid. des Sc. 3Ied., 1816); Epidemic Gastric Fever {Cheyne, 1833); 
Gastric Fever {Craigie, 1837). 

Febris mesenterica maligna {Baglivi, 1696; Hoffmann, 1728); Febris intesti- 
nalis et mesenterica {Riedlin, 1705); Febris mesenterica acuta {Burchard, 
quoted by Burserius, 1785); Fifevre entero-mesenterique {Petit and Serres, 
1813); Enteritic Fever {Mills, 1813); Gastro-enterite {Broussais, 1816); 
Entero-mesenteric fever {Abercrombie, 1820); Dothinenterite {Bretonneau, 
1825; Christ ison, 1840); Enterite Folliculeuse {Forget, 1841); Muco- 
enteritis and Gastro-enteric Fever {var.) ; Enteric Fever ( Wood, 1848 ; 
Aitken, 1858). 

Many of the cases decribed by Cullen and his successors, under the designa- 
tiofi Enteritis erysipelatosa, luere probably examples of this fever. — (See de- 
scription of it in Alison's Path, and Pract. of Med., p. 323.) 

lY. Simple Fever or Febricula. 
Characters. — A sporadic, non-contagious disease, arising from exposure to the 
sun, fatigue, surfeit, inebrity, etc. Its symptoms are : frequent, full, and firm 
pulse ; white tongue ; great thirst ; constipation ; high-coloured urine ; very 
hot and dry skin ; no eruption ; severe headache, and sometimes acute delirium ; 
the fever subsiding in from one to ten days, vt^ith copious perspirations, herpetic 
eruptions, etc. In the dead body, congestion of all the internal organs. 

Synonyms. 

Kaiffo? {Hippoc); Causus sive Febris ardens {Galen, Willis, 1659; Boerhave, 
1738); Synochus causonides {Forestus, 1591; Mangetus, 1695); La Calen- 
tura? {Piquer, 1751); Causes {Vogel, 1764); Endemical Causes {Mosely, 
1789); Enecia Cauma {Mason Good, 1817); Ardent Fever {Burnett, 1812; 
Ranald Martin, 1841 ; Copland, 1844) ; Ardent Continued Fever {Morehead, 
1856). 

'Zvvoxoit {Greeks); Synocha vel Synochus Simplex {Riverius, 1623; Hoffmann, 
1700; Juncker, 1736; Burserius, 1785); Synocha {Linnceus, 1763); Saio- 
vages, 1768; Cullen, 1769); La Fifevre Synoque {Davasse, 1847); Syno- 
shische {Germ.). 

Synochus imputris? {Galen); Febris continua non putrida {Lemmius, 1563; 
Boerhave, \T^^); Synocha sine putredine {Sennertus, 1641); Synocha non 
putris {Bellini, 1732); Febris non putrida {Quavin, 1781). 

2w5;^>75 ^xsyjuatwSf?? {Gr.); Febris Sanguinea? {Avicenna); Synocha sanguinea ? 
{Sennertus, 1641) ; Feb. acuta sanguinea {Hoffmann, 1700); Febris venosa 
{Ballonius, 1734); Acute Continual Fever {La.ngrish, 1735); Simple In- 
flammatory Fever {Huxham, 1739; Fordyce, 1791); Febris acuta simplex 
{Storck, 1741); Synocha plethorica and Ephemera plethorica {Sauvages, 
1716); Febris continens inflammatoria simplex {Selle, 1770); Febris acuta 
{Ploucquet, 1791); Entzundungsfieber and Entzundliche Fieber {Reil, 1794, 
etc.); La Fifevre angiotenique {Pinel, 1798); La Fievre angiotenique pure 
et simple {Bouillaud, 1826); Fifevre inflammatoire {Fr.); Febbre inflamma- 
toria {Ital.). 

Febris depuratoria? (§wesnay, 1753); Judicatoria? (-Sa^ar, 1776). 



234 Progress op the Medical Sciences. [Jan. 

Febris septenaria {Platerius, 1656 ; Sprengel, 1814) ; Ephemera plurium dierum 
{Sennertus, 1641 ; Juncker, 1736); Synechia septimo die soluta {Hoffmann, 
1700); Febris continens ? {^tahl, 1700); Febris continua simplex {Ldeutaud, 
1776); Simple Continued Fever {modern writers). 

Febris ephemera {Rwerms, 1623 ; Sennertus, 1641 ; Sauvages, 1768) ; Diary 
Fever {Strother, 1728); Ephemera simplex {Boerhave, 1738); Febris diaria 
{Juncker, 1736; Linnceus, 1763); Fifevre ephemfere {Davasse, 1847); Febri- 
cula {var. and Jenner, 1849, not the Febricula of Manningham) ; Das en- 
tagige Fieber {Germ.); Effimero {Ital.)-, Efemera {Span.). 

Ephemera a frigore and E. a calore {Sauvages, 1768) ; Sun Fever {Scriven, 1857). 

10. Symptoms and Treatment of Diphtheria. — We find in the Lancet (Nov. 
6th) the following remarks, by Dr. 0. D. Kingsford, on the symptoms and 
treatment of diphtheria, a disease which is now prevailing epidemically in some 
parts of England. 

" Diphtheria may be divided into the mild and the severe forms. 

" The mild form, which, for the sake of distinction, may be designated the 
diphtheritic sore-throat, is ushered in by a variable amount of feverishness, loss 
of appetite, and at first only slight pain in swallowing ; the tongue presents a 
thick, white, creamy coat, through which some of the papillae are visible ; the 
velum palati, uvula, and pharynx are of a bright-red colour ; the tonsil glands 
are much swollen and of the same livid hue, and upon the inner side of one or 
both of them distinct white patches are seen, which in some instances resemble 
an exudation from the sulci of the tumid gland, but more frequently are flat and 
filmy in appearance, not confined to the tonsils alone, but spread over the uvula 
and posterior wall of the pharynx : both the exudation and the filmy deposit adhere 
tenaciously to the submucous surface, and cannot easily be scraped ofi". Ulcer- 
ative stomatitis not rarely precedes and accompanies this mild form of diph- 
theria ; indeed, by some, they are considered to be identical ; the parotid and 
submaxillary glands are not much swollen, although one or two enlarged glandulaj 
concatenatse may often be detected. 

" The severe form, or genuine diphtheria, is always characterized by a high 
state of fever, a hot pungent skin, flushed countenance, congested lips, a rapid 
feeble pulse, great difficulty in swallowing, and hurried respiration ; the tongue 
is covered by a thick, dirty, yellowish-brown, or sometimes slaty-coloured coat ; 
the velum palati, uvula, and pharynx are of a deep, dusky erysipelatous redness ; 
the tonsils usually enormously swollen and of the same dark-red colour, but in- 
stead of the white patches observed in the mild form, a large ash-coloured mem- 
brane is spread over the inner side of one or both tonsils, and also upon the 
uvula and posterior wall of the pharynx. As the disease advances, the above 
symptoms increase in severity ; the breathing becomes stertorous from mechani- 
cal obstruction ; deglutition so painful that young children will refuse to swallow 
even liquids ; the saliva dribbles from the mouth, and a foul, acrid discharge 
often flows from the nares ; the pulse becomes more rapid and feeble ; the glands 
of the neck are now swollen and tender, and the voice is hoarse and indistinct ; 
the patient, restless, tosses about in the bed, or else lies on his back in a semi- 
comatose state. These cases, when fatal, terminate either by rapid prostration 
of the vital powers, or by an affection simulating croup, from extension of the 
diphtheritic membrane into the air-passages ; in both instances, death is usually 
preceded by obstinate vomiting, probably the result of inflammation or irritation 
of the par vagum. 

The prognosis must, at all times, be very guarded, but will depend much 
upon the disease being from the first recognized and energetically treated ; for 
the mild form, if left alone or improperly handled, will quickly pass into genuine 
diphtheria, when the prognosis becomes more unfavourable, although modified 
by the duration of the disease, and the age and temperament of the patient. 

"The treatment is divided into constitutional and local, and varied according 
to the severity of the case. Even in the mild form, or diphtheritic sore-throat, 
it will be found advisable, in the first instance, to confine the patient to bed in a 
well-ventilated room ; if the bowels be sluggish, a brisk calomel purge should be 
given, but under no circumstance should any other antiphlogistic measure be 



1859.] Medical Pathology and Therapeutics. 



235 



resorted to, but a liberal diet at once enjoined, consisting of strong beef-tea, port 
wine, jellies, and farinaceous food, which ought to be administered at short in- 
tervals, and in moderate quantity. The following draught to be taken every 
three or four hours : Chlorate of potass, from ten to thirty grains ; dilute hydro- 
chloric acid, ten to thirty minims ; decoction of bark or water, half an ounce to 
an ounce. The dose of the salt and mineral acid to be increased according to 
the age of the patient. The topical treatment consists of sponging the fauces, 
two or three times a day, with the compound solution of alum (L.^P.), (by means 
of a piece of soft sponge attached to the end of a pen-holder, or portion of 
whalebone) ; the patient also, if not too young, should gargle frequently with a 
strong solution of alum. The speedy removal of the white patches, by this local 
application of alum, renders highly probable the suggestion that the deposit is a 
fungus. 

" In treating the severe form, or genuine diphtheria, it is most important to 
guard against being misled by the feverish excitement, and thereby be induced 
to adopt antiphlogistic remedies. It should be borne in mind, that the fever is 
the result of a poison analogous in type to adynamic erysipelas ; and as it would 
be unwise to treat the latter disease by lowering the system, so would any de- 
pleting means, for the purpose of reducing the fever attending diphtheria, be 
fraught with danger. The pharynx should be sponged every eight hours with a 
solution of lunar caustic (sixteen grains to an ounce of distilled water), and for 
this purpose the sponge, by being easily compressed between the swollen tonsils, 
will be found preferable to a brush. A most liberal allowance of wine and nu- 
tritious diet must be instituted from the first, and the following draught : Chlo- 
rate of potass, from ten to thirty grains ; tincture of sesquichloride of iron, ten 
to thirty minims ; syrup, a drachm ; water, seven drachms : given every one, 
two, or three hours, according to the age of the patient and the degree of py- 
rexia present ; the more intense the inflammatory symptoms, the oftener should 
the draught be exhibited ; nourishment also should be given in definite quanti- 
ties at short intervals. It will happen, not unfrequently, with very young chil- 
dren, that some time before the mechanical obstruction precludes deglutition, all 
voluntary eSbrts at swallowing will be obstinately resisted, from pain, and disin- 
clination to be aroused. These cases excite the greatest anxiety, as unless a 
suflBcient quantity of support can be taken, the vital powers must quickly suc- 
cumb to the influence of the poison. Still all attempts to give medicine or food 
by the mouth should now be discontinued, and an enemata of strong beef-tea and 
port wine (one ounce of each) be administered, per rectum, every two hours ; 
also, for a child above three years old, five grains of quinine should be added to 
each alternate injection. At bedtime, to procure rest, it may be advisable to 
add five minims of Battley's sedative. The glysters may be thickened with 
arrowroot ; and, at intervals, milk substituted for the beef-tea and wine. The 
quantity injected should never exceed two or three ounces at a time (or it will 
fail to be retained) : and hence the necessity for the frequent repetitions. The 
topical application of the nitrate of silver must be persevered in, and the patient 
allowed to sip any nutriment he will. By adopting this procedure, time is 
gained, and life maintained until the virulence of the poison is overcome or ex- 
hausted. Mercury, in any form, excepting as a cathartic at the onset of the 
disease, seems to be especially contra-indicated. Blistering and external stimu- 
lants to the neck are worse than useless, by adding to the irritability of the 
sufferer, without exercising any beneficial or derivative effect upon the fauces. 

Tracheotomy, if entertained, should be adopted immediately the croupy 
symptoms have become established, and not deferred as a dernier ressort. The 
presence of vomiting I should consider sufficient proof that the disease had 
already advanced too far to warrant any hopes of success from an operation. 

" It will be observed that the plan of treatment above advocated is based upon 
that of two analogous affections, viz., ulcerative stomatitis, and acute asthenic 
erysipelas of the head and neck ; viewing the mild form of the disease as allied 
to stomatitis, and therefore prescribing the chlorate of potassa with the mineral 
acid ; but regarding diphtheria as a complication of diphtheritic sore-throat with 
erysipelas, and hence ordering, in addition to the salt, large and frequently- 
repeated doses of the sesquichloride of iron. 



236 



Progress of the Medical Sciences. 



[Jan. 



" The question of infection is very difficult of solution, yet the rapid spread of 
the malady in schools, and the recorded deaths of several members of a family 
from this disease, render it inoperative that every precaution be used to prevent 
its dissemination. In some cases, I have most conclusively traced the origin of 
the disease to emanations from putrid, stagnant ponds and sewers. 

" When the affection of the throat assumes the malignant or putrid type, 
which is recognized by a livid, gangrenous appearance of the tonsils, and by an 
intolerable fetor of the breath, the treatment recommended for genuine diph- 
theria, with the 'addition of a gargle consisting of one drachm of liquor chloride 
of lime and eight ounces of water, will be found most serviceable. 

A very serious complication occasionally arises as a sequela to the severe 
form of diphtheria, viz, paralysis of the muscles of the neck, of the pharynx, and 
of the larynx. Dr. Gull, who has already drawn attention to this subject, in- 
forms me that he has met with a case in which the upper extremity was in- 
volved ; and this morning I was consulted by Mrs. C , who was recovering, 

not only from loss of speech and of deglutition, but also from partial blindness, 
and paralysis of both arms, the result of this formidable complaint. These cases 
are to be treated upon tonic principles, by change of air, and those remedies 
which are calculated to improve the . general health. The nervine tonics are 
especially indicated. When the head falls forward upon the chest, from paraly- 
sis of the spinal accessory nerve and cervical plexus, great relief and comfort 
will be afforded by a collar of soap plaster spread upon leather. Also when, 
from paralysis of the glosso-pharyngeal nerve, the efforts to swallow are attended 
by violent fits of choking, all medicines and a large proportion of nourishment 
must be administered per rectum. Even under the most favourable circum- 
stances, recovery will be slow and gradual ; but when the phrenic nerve is im- 
plicated, the greatest danger to life is threatened. 

" In fatal cases, the post-mortem examination reveals the ash-coloured mem- 
brane spread over the pharynx, extending into the posterior nares and down the 
oesophagus ; but when death is preceded by symptoms of croup, it is found also 
in the larynx and trachea. Upon detaching this membranous exudation, the 
submucous surface presents an ecchymosed appearance, but no distinct signs of 
ulceration. 

"In conclusion, I would most strongly urge the importance of injections in the 
treatment of the severer forms of diphtheria ; nor ought they to be delayed until 
the patient is unable to swallow, but administered as soon as he ceases to take a 
sufficient quantity of nourishment. I would likewise beg to add my conviction, 
that if a sthenic plan of treatment were adopted from the very commencement 
of an attack, the mortality from this now much dreaded affection would be 
greatly reduced." 

11, Diphtheria. — Dr. Semple called the attention of the Medical Society of 
London (Oct. 18) to a disease which was exciting very great interest at the present 
moment — namely, diphtheria. He had been called down to Bagshot to see some 
cases of the affection in question, but he arrived about an hour after one of the 
patients had died ; he found that the last fatal case was the third in the same 
family, the ages of the patients being respectively eight, twelve, and fifteen years. 
They died at intervals of about a week from each other ; and while the funeral 
service was being performed on one of the children, the death of the elder sister, 
aged fifteen years, occurred. Dr. Semple, however, repaired to the house of the 
patient, in company with Dr. Blount, of Bagshot, and obtained permission to 
make a post-mortem examination of the body, although to a limited extent. It 
was to be regretted that very few examinations after death had been obtained in 
this disease, owing to the prejudices existing in the minds of relatives, especially 
in the rural districts. However, nearly the whole of the diseased parts were ex- 
amined, consisting of the tonsils, a part of the tongue and of the pharynx, the 
epiglottis, the larynx, and the trachea. On the whole of these parts the pellicu- 
lar membrane, which is the characteristic feature of true diphtheria, was de- 
veloped. It was especially necessary to bear this character in mind, because he 
(Dr. Semple) had reason to believe that, at the present time, many affections of 
the throat were confounded together, under the name of diphtheria, which had 



1859.] Medical Pathology and Therapeutics. 



237 



very little relation to that disease — at least in the sense in which the term was 
used by Bretonneau, Trousseau, Guersent, and other French writers. It was 
especially necessary to exclude the scarlatinal sore-throats from the category of 
diphtheria, because scarlatina has no real or necessary connection with the diph- 
theria epidemic. Other cases which were confounded with diphtheria were, ul- 
cerated sore-throats of various kinds, cancrum oris, and even common tonsillitis. 
The true distinction existing between diphtheria and the malignant ulceration of 
the tonsils in scarlatina, was to be found in the circumstance that the pellicular 
exudation in diphtheria may be readily removed by the handle of the scalpel, 
leaving the mucous membrane below it, congested indeed, but smooth and entire ; 
whereas, in the malignant ulceration of scarlatina, the substance of the tonsils is 
actually eaten away and destroyed. The fatality of diphtheria was quite appalling. 
Dr. Blount had attended eight cases of the disease in the vicinity of Bagshot, and 
every one of them had been fatal. Both the commencement and the termination 
of the disease were marked by peculiarly treacherous and insidious characters ; 
the symptoms, at first, are so slight, that they are hardly noticed by the patients 
or their relatives ; and when medical advice is at last sought for, the pellicular 
exudation has generally reached the air-passages, when the hopes of recovery 
are almost extinguished. The termination of the disease is equally insidious, 
and is often quite unexpected ; for although many patients die with symptoms of 
well-marked asphyxia, yet others perish suddenly by syncope while they appear 
to be going on favourably. Dr. Semple was remarkably struck with the circum- 
stance that the locality, where these fatal cases occurred, was not one where one 
might expect, a 'priori, a malignant and fatal form of disease to prevail ; for the 
surrounding country was open and beautiful, the soil dry, and the patients by 
no means placed in unfavourable hygienic conditions ; nor did it seem that the 
disease attacked ill-fed or puny children, for the girl, whose body was examined, 
was a plump, well-formed person, moderately fat, and with good muscular develop- 
ment. The therapeutical management of this disease was a question of the great- 
est importance ; but, hitherto, all kinds of treatment had been attended with very 
unsatisfactory results ; the best treatment was, unquestionably, the application 
of strong caustics to the throat, at the very earliest possible period ; and the 
hydrochloric acid, used in a concentrated form, was, perhaps, the best. This 
appears to stop the progress of the false membrane into the air-passages, and acts 
somewhat in the same manner as concentrated nitric acid in preventing the pro- 
gress of phagedsenic ulceration. When the false membrane has reached the 
trachea and bronchi, there is very little hope for the patient. The next question 
is whether, when this extension has taken place, the operation of tracheotomy — 
so much extolled and so extensively practised by the French physicians — ought 
to be resorted to. In the case of the girl at Bagshot, Dr. Semple was prepared 
to recommend the performance of the operation, if he had found the patient alive, 
and if she were suffering from the symptoms of asphyxia ; but the 'post-mortem 
examination proved that this proceeding must have been useless, for the false 
membrane was so extensively spread over all the air-passages that it could not 
have been removed, and it had so little tenacity that it would have broken under 
the forceps used for extracting it. True diphtheria, therefore, was characterized 
by the presence of the false membrane at the back of the mouth, extending, in 
the fatal cases, into the air-passages, and causing death by obstructing the re- 
spiration ; and it differed, on the one hand, from those sthenic forms of throat- 
disease which were accompanied by full pulse, and the other ordinary signs of 
acute inflammation ; and, on the other hand, it differed from those low forms of 
throat-disease which arose from a depressed habit of body, from unclean and un- 
healthy habitations, and from the complication of scarlatina. The extensive pre- 
valence of diphtheria, at the present day, demanded the attention of the Govern- 
ment; it was sweeping off great numbers of the rural population, both young 
children and persons verging on puberty ; and from the peculiarly insidious na- 
ture of the early symptoms, it was generally neglected until remedial means were 
of no avail. — Lancet, Oct. 23d, 1858. 

12. On the Non-Periodical Fluctuations in the Frequency of Pneumonia, espe- 
cially during the Tears 1836-1856. — Dr. W. Ziemssen, Lecturer at the University 
No. LXXIIL— Jan. 1859. 16 



238 



Progress of the Medical Sciences. 



[Jan. 



of Berlin, presents the results of very extensive statistical inquiries, embracing 
mortuary registers of twenty-two localities scattered over different parts of the 
world. The variation of frequency differs very considerably ; the average mor- 
tality from pneumonia in different places in England, Germany, France, Switzer- 
land, Denmark, and America being 1.53 ; the maximum mortality in the same 
places from this disease was found to be 2.00, the minimum 1.08 per cent. On the 
other hand, the variation in the same place from year to year is very considerable ; 
the author calculates that, assuming the mortality from pneumonia to be called 
100, the annual fluctuation must be regarded as 19 per cent. This fluctuation 
does not appear to depend upon the influence of climate. From an examination 
of our Kegistrar-Greneral's Reports, Dr. Ziemssen gathers that the fluctuation of 
the mortality from pneumonia in London does not vary as much as diseases which 
occur epidemically — as measles and hooping-cough; while it varies much more 
than that produced by diseases which result chiefly from constitutional and gene- 
ral vital conditions. On examination of the curves representing the mortality of 
the twenty-one years (from 1836 to 1856) , we find that the years 1838, 1840, 1842, 
1844, 1847, 1849, 1851, 1853, and 1856 are characterized by a very high position 
in the scale, 1847 being the year in which the highest point was attained. The 
years 1836, 1839, 1841, 1845, 1846, 1848, and 1850 were the years in which the 
mortality was lowest. The fluctuations occurring during these twenty-one years 
may be regarded as a pneumonic wave, rising from the year 1836 to 1838, and 
then falling to 1839 ; again rising to 1840, and falling in 1841 ; a third elevation 
occurs, reaching its climax in 1842, and gradually sinking till 1846 ; the next ele- 
vation in 1847 is followed by a slow descent till 1850 ; a fifth rise takes place in 
1851; a sixth, with the climax in 1853 and 1854; and a seventh, of which the 
highest point was in 1856. We can only find space to dwell upon one or two of 
the author's remarks. 

The year 1847 was a generally pneumonic year. Of nineteen European locali- 
ties of which the author has obtained the statistics, twelve attained their absolute 
maximum during this year; they comprised Great Britain, France, Germany, 
Scandinavia, and Eastern Russia ; none of the localities show a diminution during 
this year. It appears from a statement by Dr. Rigler, which does not, however, 
possess absolute statistical accuracy, that during the same year pneumonia at- 
tained an unusual height in Constantinople ; and, again, according to Dr. Stratton, 
that the same was the case among the North American Indians. 

With regard to the relative mortality of the two sexes, it appears that females 
bore the exact ratio to the general variations that characterized the different 
years. On examining the different ages, greater fluctuations were found to occur 
in childhood than in adult life ; and it also happened that a pneumonia epidemic 
prevailing among children scarcely affected grown-up people ; while, vice versa, 
an unusual number of pneumonias might affect adults, and not be equally appa- 
rent among the children of the same locality. 

In a brief review of the other diseases prevalent at the same time, Dr. Ziems- 
sen concludes that the prevalence of pneumonia bears no proportion to the pre- 
valence of other inflammatory disorders ; and that, therefore, to determine the 
epidemic constitution, it is advisable to classify diseases, not according to noso- 
logical divisions, but according to the organs affected. 

The whole paper is one of great value, and deserves to be specially studied by 
those who wish to appreciate the bearing of statistics upon the geography and 
history of diseases. Before concluding this notice, we would also draw attention 
to another careful essay by the same author, on the periodical fluctuations of 
pneumonia during the different seasons of the year;' in which he shows that 
while considerable variations take place in different localities as compared with 
one another, each locality presents great uniformity as to the comparative fre- 
quency of pneumonia at certain seasons. — Brit, and For. Med.-Cliir. Rev., Oct., 
1858, from Vierteljahrschriftfur die FraJdische Heilkunde, 1858, Band ii. 

13. Clinical Flustrations of the Fatliology and Treatment of Delirium Tre- 
mens. — This is the title of a very interesting paper {Edinburgh Med. Journ., 

' Archiv.fiir Physiologisclie Heilkunde, Jahrgang 1857, Drittes und Viertes Heft, 
p. 393. 



1859.] 



Medical Pathology and Therapeutics. 



239 



Oct. 1858) by Prof. Thos. Laycock. The diversity of opinion in the medical 
profession, he remarks, as to the nature, causes, and treatment of delirium tre- 
mens, is remarkable. On one point only is there an approach to unanimity, and 
that is as to the propriety, and even necessity, of administering full doses of 
narcotics to induce sleep. Prof L.'s experience has long convinced him of the 
dangers of this practice, and of the fallacies of the theories which have led to it. 
He has never, he states, witnessed a fatal case in which they had not been ad- 
ministered, while he has known many cases recover very happily without them. 

"Delirium tremens," he observes, "is usually understood to be a disease con- 
sequent upon the sottish or excessive use of alcoholic or fermented drinks, and 
characterized by tremors of the limbs, disordered intelhgence, hallucinations, 
and sleeplessness. These leading symptoms may supervene upon other causes, 
as starvation, fever-poisons in the blood, wounds, epileptic attacks, albuminuria ; 
but in these cases the delirium has another name; or opium, Indian hemp, to- 
bacco, etc., may, in rare instances, induce them. 

" But it is only a few of those who drink hard that have delirium tremens at 
all ; while those drunkards who have it are subject to it paroxysmally, or suffer 
only occasionally under certain conditions. It is of primary importance, there- 
fore, to determine what those conditions are. Now, as the disease is one of 
cerebral disorder, we may conclude that they have reference, 1, to the condition 
of the brain or of its vessels; 2, to the condition of the blood circulating 
therein ; 3, to the condition of important viscera in close relation with morbid 
conditions of the blood or of the brain. Under these three heads may be classed, 
as follows, the more important of the predisposing and exciting causes of the 
disease, i. e., the conditions necessary to an attack : 1. Conditions of the brain 
or of its vessels, [a.) Habitual stimulation from any cause, whether it be (1) 
more materially and mechanically by drugs, as spirits, wine, malt liquor (with 
its constituent adulterating drugs), or opium, ether, etc.; or (2) psychically, as 
from over-thought, over-work mentally, continued anxiety, strong emotions, 
sexual indulgence. (6.) Constitutional predisposition to irregular cerebral ac- 
tion, known as the nervous temperament, and characterized by a predisposition 
to 'nervousness,' insanity, epilepsy, and other convulsive diseases, neuralgia, etc. 
To this class of patients the oinomaniacs or dipsomaniacs belong, (c.) Condi- 
tions the result of antecedent or actually existing (but insidious) disease of the 
brain or its membranes, such as attacks of 'brain fever,' infantile disorders 
affecting the brain or membranes, tuberculosis, and especially the sequelae of 
mechanical injuries done to the cranium, and which at the time of occurrence 
attracted perhaps little attention, {d.) Recent injuries to the head received in 
the drunken state, or diseases affecting the brain especially, which have come on 
very recently, as masked gout, certain forms of bronchitis, pneumonia, and peri- 
carditis; inflammation of the liver, spleen, kidneys, etc. 2. Conditions affecting 
the hlood. [a.) Alcohol in the blood predominantly. (&.) Defective supply of 
nutrient materials in the blood, consequent on loss of appetite or inability to 
digest food, (c.) The presence of fever-poisons, {d.) Retained excreta, as car- 
bon or carbonic acid, bile, urea, etc. 3. Conditions of important viscera, [a.) 
Inflammatory affection; gastritis is hardly ever absent; duodenitis, with consti- 
pation, frequent; hepatitis and chronic nephritis, or chronic congestion of the 
Iddneys, by no means rare. (&.) Structural diseases — as of the liver (fatty de- 
generation, cirrhosis), of the stomach (chronic thickening, ulceration), and of the 
kidneys (Bright's disease, cirrhosis), may be looked for. These are mentioned 
as predominant conditions ; they do not exclude, however, other causes of mor- 
bid change in the brain and in the blood, and which are presented in cases of 
delirium tremens in great variety. Perhaps the most noticeable and important 
is the sleeplessness so constantly observed to precede and accompany the deli- 
rium, and which, itself a result of morbid changes, is usually, in its turn, a 
cause of those further morbid changes in the brain upon which both it and the 
delirium depend. 

" Now, the treatment of delirium tremens consists essentially in the treatment 
of these conditions ; this object being satisfactorily attained, the symptoms cease, 
i. e., a cure is effected." 

Prof. L. adduces a number of cases illustrative of these views. 



240 Progress op the Medical Sciences. [Jan. 



The general rules laid down by Prof. L. for the treatment of delirium tremens 
are as follows : — 

" 1. The patient should be placed in as complete a state of muscular repose 
as possible. To this end, he should, if practicable, be kept in bed. Muscular 
activity necessarily exhausts the nervous system ; hence, quiet of the muscular 
system facilitates repair of nervous energy. If, however, the patient cannot be 
kept in bed without mechanical restraint, it is on all hands allowed to be better 
not to restrain him, as the waste of motor power is much greater in the con- 
tinued attempts the patient makes to keep from restraint, than in his usually 
quiet wanderings after unmeaning objects. Should his delirium be of the violent 
kind, absolutely needing restraint, chloroform would, perhaps, be in general a 
safer remedy than the strait waistcoat, although not a remedy to be administered 
without serious consideration as to its fitness in each case. 2. All sensational 
stimuli should be removed, and all emotions, agitating thoughts, or anxieties, be 
prevented. 3. Food of a suitable kind should be carefully given from time to 
time ; no alcoholic stimuli of any kind administered as articles of diet, unless 
specially indicated. 4. Where there is a tendency to diaphoresis, it should be 
encouraged as an eliminatory process. 5. The surface, and especially the feet, 
should be kept comfortably warm. If the head be hot, the hair may be cut 
short, and a gentle douche, for one or two minutes, applied every three or four 
hours ; this is rarely necessary, however, much less shaving the scalp. 6. An 
experienced nurse must attend the patient. But, above all, it is essential that 
the practitioner be clear in his etiological diagnosis, so that he may be knowing 
as to the powers of nature. He should first determine whether the patient be 
under the influence of alcohol or not, and ascertain clearly whether there be any 
important complications. If the patient be alcoholized, and no important com- 
plications be discovered, he may consider the sleeplessness and delirium as of no 
great pathological importance, and calmly and confidently await the result of a 
few days' judicious watching and general management of the case." 

14. Uses of Bleeding in Diseases. — Dr. W. 0. Maekham read (Nov. 23) an 
instructive paper on this subject before the Eoyal Med. and Chirurg. Soc. The 
object of the author is to show, that by arguing from certain admitted facts 
respecting the effects of bleeding, a rule of practice may be deduced, indicating 
the right application of the remedy in diseases. The conclusions at which he 
arrives are these : — 

1. There is no proof that venesection has any cZ^Vec% beneficial influence over 
the progress of inflammations, either external or internal. On the other hand, 
the injurious effects of large bleedings, especially in those inflammations in which 
the integrity of the lungs is seriously compromised, have been often demon- 
strated. 

2. Nevertheless, venesection is, at times, of great service indirectly in the 
course of inflammations, and of all other diseases which occasion congestion and 
oppression of the heart, by removing this secondary consequence, which arises 
accidentally out of the inflammation. 

3. In all cases in which venesection is of service, it acts alike — viz., by re- 
lieving the cardiac congestion : it neither arrests nor modifies beneficially the 
inflammatory process. 

4. A marked distinction is to be drawn between the efiects of bleeding in 
inflammations and the local abstraction of blood from an inflamed part. Local 
abstraction of blood materially influences the inflammation, reducing the most 
characteristic of its phenomena — the pain, the heat, the redness, and the swell- 
ing ; but it only influences, in this way, internal inflammations when there is a 
direct vascular connection iDetween the part inflamed and the part whence the 
blood is drawn. 

5. It is not denied that local irritation of an external part may influence an 
internal inflammation (even when there is no direct vascular communication be- 
tween the skin and the inflamed part) by reflex action, conveyed thence from the 
skin through the vaso-motor nerves of the inflamed part. 

The author demonstrates the inefificacy of venesection over internal inflamma- 
tions in two ways : 1st, by arguing of what is seen of its inutility in external 



1859.] Medical Pathology and Therapeutics. 



241 



inflammations ; and, 2dly, by the fact of the large and general concurrent testi- 
mony of modern experience, which has proved that large bleedings — the only 
bleedings whicli have any manifest influence over inflammations — are often very 
injurious, their good effects being dubious and disputed. 

Venesection has been long since abandoned in the treatment of external in- 
flammations because of the danger and inutility of the practice ; and though less 
easily traced in the case of internal inflammations, the same conclusion has 
gradually forced itself on the minds of observers. The practice is no longer 
regarded as essential in their treatment ; but the author cannot believe that phy- 
sicians have been during so many ages, and still are, acting under a delusion as 
to the services rendered by venesection in internal inflammations. He, there- 
fore, endeavours to explain the discrepancy by assuming the position — that 
venesection, as regards internal inflammations, is of service, not through any 
direct influence which it exercises over the inflammatory process, but in conse- 
quence of its removing certain of the secondary consequences which arise acci- 
dentally out of the inflammation — to wit, the oppressed and congested condition 
of the heart. He asserts that venesection is never required excepting when this 
congestion of the heart exists ; but at the same time observes, that there are 
congestions of the heart, and periods in the course of all congestions, in which 
no relief can be hoped for from the remedy. Modern experience justifies this 
position : for venesection is rarely ever practised now, except in those diseases 
in which this congested condition of the heart necessarily plays a prominent 
part. The benefits, indfaed, of venesection become more clearly manifest in pro- 
portion as the disease for which it is practised produces a higher degree of this 
congestion. As illustrations of this, cases are related in which the original dis- 
orders, provoking this congestion of the heart, lay respectively in the heart itself, 
in the lungs, in the abdomen, and in the brain. In all of them the same condi- 
tion of the heart, and the same symptoms were present, claiming a similar treat- 
ment. The relief given by venesection^ in three of these cases, was immediate 
and permanent ; in two of them, no inflammation existed ; and, in the third — one 
of pneumonia — the venesection had no influence over the inflammation of the 
lung, for the stethoscope demonstrated that the portion of the lung inflamed was 
in the same condition of consolidation the day after as on the day of the bleed- 
ing ; in the fourth case — injury of the head — the man was not bled, and died, the 
immediate and only apparent cause of death found being extreme congestion of 
the heart and lungs. Bleeding, it is believed, would have saved this man's life. 

He ofiers the same explanation of the benefit of venesection in wounds of the 
lung, long before inflammation exists, and he thinks that the same circumstances 
explain the relief of the pain often attendant on pneumonia, which, while occa- 
sionally due to pleurisy, he thinks more frequently produced by cardiac conges- 
tion — a pain which is sometimes felt when there is no pleurisy, or may not be felt 
when pleurisy is present. In certain conditions of disease of the heart and great 
vessels, in injuries of the head and apoplexy, and even in peritonitis, the benefits 
occasionally following venesection may all, he thinks, be referred to the relief of 
cardiac congestion. Such an explanation seems to the author clear and simple, 
and in complete accordance with our physiological knowledge and our practical 
experience ; and with reference to any other beneficial and direct actions, which 
venesection is supposed to exert over inflammation, he observes that all our 
knowledge of the effects of venesection has not yet enabled us to show what those 
other actions are ; and all our modern experience manifestly tends to prove that 
venesection has no directly beneficial influence over inflammations, but that, if 
large, it acts injuriously by weakening the system, which has to sustain the force 
of the inflammatory process. 

If the facts here maintained be correct, then it necessarily follows that the 
objects of, and indications for, venesection become clear and definite, and that a 
rule of practice may be established from their consideration. It also follows that 
venesection is now-a-days less frequently practised than is desirable ; that it must 
have been of service in other days, just as it is of service now ; that it is requisite 
now, just as it was requisite then. 

The author next refers specifically to venesection in pneumonia. Here there 
are two main special facts to be considered, which contraindicate to a certain 



242 



Progress of the Medical Sciences. 



[Jan. 



extent tlie venesection : 1 st, the diseased condition of the lungs, which produces 
the cardiac congestion, cannot be removed by the bleeding ; 2d, the loss of blood 
is, so long as the pneumonia lasts and in proportion to its extent, an irreparable 
loss. Hence it follows that the more extensive the inflammation, and the more 
urgent the symptoms, the greater is the danger of venesection ; and in fact, just 
in proportion as the bleeding is more required to relieve the heart, is the prac- 
tice of it less applicable. In pneumonia, the function of the chief sanguifi eating 
organ of the body is arrested ; and therefore to take away blood at such a time 
is to take away what cannot be restored so long as the inflammation lasts. The 
loss of blood, which might be borne with impunity in other inflammations, seri- 
ously compromises the future of the patient in this inflammation of the lungs. 
Venesection, he says, is applicable in pneumonia when the general symptoms 
have arisen rapidly and are severe, aud when the inflammation is limited, as in 
the case related — when the urgency of the symptoms is, so to say, out of pro- 
portion to the extent of the inflammation, as measured by the stethoscope ; that 
is, when the aerating processes are not seriously and extensively compromised. 
The object of the venesection is, in all cases, to relieve the heart from its tempo- 
rary embarrassments. When the congestion of the organ is the consequence of 
its own partial paralysis, then of course venesection cannot restore to it its 
equilibrium. 

With reference to the local abstraction of blood. Dr. Markham points out the 
importance of vascular connection between the skin and the inflamed organ, rea- 
soning from the analogy of external inflammations. The benefit of leeches in 
pneumonia he refers simply to the attendant inflammation of the parietal pleura, 
and thinks that in pericarditis the pain is frequently due to concomitant pleurisy, 
and is relieved in the same way. In endocarditis, he believes they can be of no 
service ; nor can they draw one drop of blood from an inflamed liver or kidney. 
In such cases he conceives that the benefits attributed to cupping or leeches may 
be due to other remedies employed at the same time. 

The author makes no attempt at any explanation of the mode of action of 
either venesection or local abstraction of blood. If the facts stated be true and 
rightly interpreted, their practical deduction may be accepted, without waiting 
for any theoretical explanation of them. 

Dr. Mayo, after passing a high eulogium upon Dr. Markham's paper, pro- 
ceeded to say that he agreed in the main with the views advanced by the author, 
in respect both to local and general bloodletting. He thought, however, that 
we required more definite information as to the necessity of general bleeding in 
cases of apoplexy. He related a case in which forty ounces of blood were taken 
away with immediate and complete relief. General bleeding was now almost 
prohibited in apoplectic seizures, but he thought that this was to some extent a 
mistake. He agreed with the author that the simultaneous employment of 
bleeding and stimulants was not inconsistent in certain diseases ; for whilst the 
one unloaded the vessels, the other exhilarated, and by the combined measures 
the circulation was accelerated. Even in neuralgic cases, the administration of 
steel was occasionally rendered beneficial by the previous extraction of a few 
ounces of blood. In periostitis, bleeding often rendered the disease more man- 
ageable, and in a case of severe sprain of the ankle, attended by intense neural- 
gia, which had come under his observation, the extraction of seventy ounces of 
blood by Mr. Wardrop had been followed by complete relief. The life of the 
patient was, however, for some time placed in jeopardy. 

Dr. J. A. Wilson alluded to the great prevalence of bleeding a quarter of a 
century ago. He thought that in certain cases, even of intense hysteria, bleeding 
might be applied with great advantage. He related a case of this affection, 
which had supervened upon great mental emotion, and the symptoms of which 
were immediately arrested by the copious abstraction of blood. Bloodletting 
was not resorted to in inflammation for the direct relief of that condition, but to 
restore action and relieve the circulation. Bleeding, in years gone by, was no 
doubt carried to an unjustifiable extent, but at the present time he thought we 
had gone to the opposite extreme. Cases occurred to him in consultation in 
which the abstraction of eight or ten ounces of blood was evidently indicated, 
but in which he found the greatest difficulty in obtaining consent to that pro- 



1859.] 



Medical Pathology and Therapeutics. 



243 



ceeding. No general rule could be laid down as to the necessity of abstraction 
of blood ; in fact, every case must be judged of by the symptoms exhibited to the 
practitioner. He ridiculed the notion which had lately prevailed, that English- 
men were now less able to bear the loss of blood than formerly, because, for- 
sooth, they had degenerated in physical power. No doubt the effects of blood- 
letting were better understood now than formerly, but he emphatically denied 
that there was any degeneracy in the constitution of English people. On the 
contrary, better education and better food had improved the constitution of the 
people of this country; and if the necessity for the copious abstraction of blood 
should again arise, they would be found to bear it as well, if not better, than they 
did in former times. 

Dr. Druitt contended that Dr. Markham was wrong in asserting that any 
single circumstance was sufficient in itself to explain the beneficial effects of 
bloodletting in inflammation. Theory must succumb to practice ; even if theory 
were advanced in support of the non-abstraction of blood, logical deductions 
might be drawn to show its fallacy. Thus, if it was contended that blood was 
in excess, bleeding undoubtedly reduced the quantity of that fluid. If the blood 
were of too high a specific gravity, bloodletting reduced it. If it was necessary 
to aerate the blood, bleeding rendered that process more easy. 

Dr. Webster differed with the author with respect to local bloodletting in 
internal inflammations. He had found that in inflammatory diseases of the chest 
in children the abstraction of the blood by cupping was often of the greatest 
service. It was nothing new to find the practice vary in regard to the employ- 
ment of bleeding. It had been the case from the earliest periods ; bloodletting 
being, at one time, almost constantly employed, whilst at another time it was 
almost completely abandoned. Disease assumed different types at different 
periods. This might explain why bleeding was less resorted to now than twenty 
years ago. But it must be remembered that the time might soon arrive when 
the necessity for bloodletting would again be indicated. 

Dr. SiBsoN coincided in opinion with Dr. Markham as to the importance of 
local bloodletting in cases of local inflammation. He thought, however, that he 
had taken too confined a view as to the effects of general bloodletting. Dr. 
Markham had considered that the pain in pneumonia was attributable to direct 
obstruction in the heart itself ; but this opinion was contradicted by the fact, 
that the pain in nine cases out of ten was restricted to the seat of inflammation. 
In these cases the pain was the result of pleuritis, and was relieved by the local 
abstraction of blood. In pneumonia, bleeding was of essential service, not only 
from the relief it afforded to the heart itself, but by the influence it exerted in 
preventing the extension of the disease. But it must be remembered that there 
were other cases besides those mentioned in the paper, in which bloodletting- 
afforded great relief, independent of removing any obstruction in the circulation 
of the heart ; such, for instance, as in cerebral congestion. Whatever might be 
said with respect to other inflammations, venesection in cases of pneumonia was 
beneficial. In most other inflammations, blood could be abstracted by side cur- 
rents ; but in pneumonia, as every drop of blood had to pass through the inflamed 
lung, and there was a diminished channel for its course, it was incumbent that 
its quantity should be diminished. — Lancet, Dec. 4, 1858. 

15. Changes -produced in the amount of Blood-Corpuscles hy the administra- 
tion of Cod-liver Oil. — Dr. Theophilus Thompson read (Nov. 18, 1858) a paper 
on this subject before the Royal Society. 

The author had presented to this Society, on the 27th of April, 1854, a 
communication descriptive of the chemical changes produced in the blood by 
the administration of cod-liver oil and of cocoa-nut oil, and advanced the con- 
clusion, deduced from chemical analysis, that any favourable result derived from 
the use of these oils is associated with an increase in the proportion of red 
corpuscles. The present communication was an extension of the inquiry, but 
was confined to experiments on the influence of cod-liver oil on the blood. It 
comprehended the principal details regarding fourteen patients affected with 
pulmonary consumption in various stages of progress, and the result of analyses 
of their blood. In two instances no oil had been given ; in the remaining twelve 



244 Progress of the Medical Sciences. [Jan. 



that medicine had been more or less freely administered, and an obvious contrast 
was noted in the condition of the blood, the proportion of red corpuscles to a 
thousand parts of blood in the two cases where no oil had been given being re- 
spectively 98.20 and 119.64, and in ten of the other patients varying from 142.32 
to 174.76. In these ten cases the use of the oil had been attended with marked 
gain in weight and other evidences of amelioration. In another instance, in 
which the disease advanced, and a loss of seven pounds in weight occurred, not- 
withstanding four months' administration of oil, the proportion was 114.39. In 
one example only was a favourable effect of the oil accompanied .with a low pro- 
portion of corpuscles, viz, 84.83 ; but in this patient, haemoptysis, so profuse as 
to endanger life by increasing the poverty of the blood, had apparently modified 
to some extent the ordinary influence of the remedy. Th.e analysis was con- 
ducted by Mr. Dugald Campbell in the following manner : The whole quantity of 
blood abstracted having been weighed, the coagulum was drained on bibulous 
paper for four or five hours, weighed, and divided into two portions. One por- 
tion was weighed, and then dried in a water-oven to determine the water. The 
other was macerated in cold water until it became colourless, then moderately 
dried, and digested with ether and alcohol to remove fat, and finally dried com- 
pletely and weighed as fibrin. From the respective weights of the fibrin and the 
dry clot that of the corpuscles was calculated. 

Dr. Copland observed that consumption is a disease which tends to produce 
a continual waste of blood-corpuscles, and that whatever promotes nutrition and 
excites the vital forces must have a beneficial tendency in such a disease ; for 
with improved assimilation, there must evidently be a renovation of blood- 
corpuscles. On this principle, cod-liver oil, he believed, would be found eflicacious 
in anaemia and rickets as well as in consumption, although he was not sure that 
it had any particular advantage over iron as a remedy. 

Dr. Gakrod thought that any future researches on this subject would be still 
more valuable if the analyses were rendered more specific, by ascertaining the 
proportions not only of the red corpuscles generally, but also of the constituent 
parts of the corpuscles. Without such information, it was difficult to explain 
the fact that cod-liver oil is so far more useful in consumption than in anaemia ; 
and it would be desirable to determine the amount of change produced by such 
a remedy in the proportion of hsematin, globulin, iron, and fat, entering into the 
composition of the blood-cells. — Lancet, Nov. 27, 1858. 

16. Narcotic Injections in Neuralgia. — Chas. Huntee, Esq., House Surgeon 
St. George's Hospital, records [Med. Times and Gaz., Oct. 16th) the following 
cases of neuralgia treated by narcotic injection into the part, as proposed by Dr. 
A. Wood, of Edinburgh. 

Case 1. — J. G., aged 55, was admitted into St. George's Hospital, July 21, 
under Dr. Pitman, with tic douloureux, He had been constantly subject to it for 
four years, with but little intermission ; at one time he obtained for a few weeks 
from seven to eight hours' sleep at night, but with that exception he used always 
to be in pain day and night, and seldom slept an hour without a violent paroxysm. 

On admission he was suffering these repeated violent attacks of pain all over 
the left side of the face, which caused him day and night to keep up a cry of 
anguish. Various remedies to palliate the pain were attempted, but unsuccess- 
fully till the 7th of August, when the local injection of morphia was commenced. • 
About one grain and one-third of the acetate of morphia was injected at 8 P. M. ; 
the man fell asleep very soon after, and continued to do so for seven hours. 
During the next few nights the same dose was regularly injected, and he slept 
either all night or for several hours. 

On the 11th, he was asleep when visited, so no more morphia was injected ; he, 
however, slept two hours ; the next few nights the injection was not given ; he 
slept either not at all, or most indifferently. 

16^/i. A larger dose was injected into the cheek from within the mouth; he 
went off to sleep at once, and did not awake all night ; he was also easy the whole 
of the next day; after this the original dose was continued, both night and 
morning. 

20^7i. He sleeps a good deal ; has good nights, and two or three hours' sleep 



1859.] Medical Pathology and Therapeutics. 



245 



in the day. The paroxysms are now so slight, that often no one except the pa- 
tient can tell when they are on ; no continued pain is felt, and the paroxysms are 
"sometimes off for half a day, often for several hours." 

SOth. Until to-day the morphia has been injected night and morning; but, for 
the present the administration is left off on account of a considerable sized abscess 
which has been gradually forming the last few days, and which was opened to-day. 

The part injected was the gum over a back upper tooth, as that was the most 
painful part, and the spot which, if touched, always brought on a paroxysm ; lat- 
terly, the adjacent tissue of the cheek was injected close to the gum. 

Thus, not only was sleep procured, but the patient obtained considerable ease 
during the day while the injection was gone on with. The constant recurrence 
of the attack of pain was put an end to, and the paroxysms when they did occur 
were far milder; but a large abscess, formed in the cheek. 

Case II. — E. P., aged 18, was admitted into St. George's Hospital, July 25, 
under Dr. Tatum, suffering from excessive neuralgia in the right eye, which was 
also extensively diseased. As there were no hopes of saving the eye, and the 
pain was constant, the globe was removed for fear the other eye should also suf- 
fer ; unfortunately it did, and ran a most rapid course — the lids becoming swol- 
len, hard, thick, and everted ; the neuralgia in this eye became even worse than 
it had been in the other. 

Allkinds'of remedies were tried — aconite, morphia, hyoscyamus, opium, quinia, 
etc., all failed to give relief ; chloroform was then used and frequently, but it only 
gave her ease and sleep for a few minutes, or at the most an hour or so. 

Sept. 9. f gr. of morphia (the acetate) was injected under chloroform into the 
eyelid, but produced no sleep, as sickness (which had commenced in the after- 
noon after a dose of morphia by the stomach) continued during the night. 

10th. No morphia given by the stomach, 1^ gr. injected under chloroform into 
the eyelid ; she went off to sleep for seven hours continuously, which she had 
not done for some months. She slept also once or twice the next day without 
chloroform. 

11th. Injection repeated 10 P. M. ; a part escaped; she slept four hours; had 
acute paroxysms between the periods of sleep. 

12^/i. Sleep produced by the injection, and the severity of the paroxysms much 
diminished. 

In the next few days the morphia was injected, and gave ease and sleep in 
proportion to the amount injected; from this time no chloroform was employed 
while inserting the point of the syringe in the skin. 

IQth. Slept four hours last night. The pain now is nothing to be compared 
to what it previously was, the swelling is going from the eye. In the evening 
nearly three grains of morphia were injected; sleep was immediately produced, 
and continued eight hours. The next day she was far quieter and easier, and 
appeared so comfortable at night that no morphia was injected. 

18th. No morphia having been injected, no sleep was obtained last night, 
although a six-hour dose (gr. i.) was continued to be administered by the sto- 
mach. 

19^7i,. 1^ gr. injected into the eyebrow, gave sleep for several hours at night, 
and a little in the day ; at night two grains were given by the stomach ; it gave 
no sleep, but after an hour or so caused considerable sickness. 

Oct. 4. The morphia injection is still continued, and with considerable relief to 
the patient. 

Remarks. — In this patient, then, it appears — 

1. That a very great change has been made for the better, the progress of the 
affection appears arrested; or, at all events, for the present kept at bay; the 
health of the patient is improved. 

2. That the local affection appears so far improved that all the hardness, thick- 
ness, and eversion of the conjunctiva have subsided; the pain in the head is very 
much less, the pain in Jhe eye is far less acute, and the attacks much less fre- 
quent, so that sleep is every now and then obtained during the day without me- 
dicine. 

3. But it must be observed that this girl, like the man, has had abscess as a 



248 



Progress of the Medical Sciences. 



[Jan. 



result of tte local injection ; tlie eyelid, the eyebrow, and the side of the eye, have 
all been opened for the liberation of matter. 

4. It is very interesting to observe, that in this girl the injection of morphia 
into the cellular tissue was most effectual; but that morphia given by the stomach 
was of no benefit at all, but always did harm ; that general irritation to the ner- 
vous system was produced ; that sleep hardly ever followed, and was then pro- 
bably accidental, because so seldom, but that sickness, nausea, giddiness, etc., 
almost always accompanied its administration by the stomach, whatever the 
strength of the dose happened to be. 

In considering the results of the trial of the local treatment in the two cases, 
the advantages obtained appear to me to be — 

1. That much less constitutional (nervous) irritation attends the local intro- 
duction of the narcotic than when it is given by the stomach. 

2. That the effect of the narcotic is more immediately produced. 

3. The action of the narcotic appears more sure when injected. The exact 
amount taken into the circulation can be more readily seen, and the risk of con- 
tamination or alteration which it is exposed to, given by the stomach, is avoided. 

4. It appears to exert more benefit on the local affection when it has to be ab- 
sorbed from the part affected itself, probably from being brought more directly 
into contact with the nerves involved in the disease. 

On the other hand, there are the disadvantages ; these are chiefly — 

1. The pain occasioned by the introduction of the fine canula. 

2. The chance of the fluid escaping from the wound or puncture. 

3. The production of local inflammation, effusion of blood, abscess. 

To conclude : are the disadvantages of such import that they ought to preclude 
the local employment of narcotics by injection? do the advantages preponderate 
over them ? I think they do ; and that the disadvantages are only those which, 
with care and experience, may either be avoided, or much diminished; for in- 
stance — 1. By employing such a syringe as that used for the perchloride of iron 
(to inject aneurisms, etc.), with a very fine point to the nozzle, the pain is not 
more than that occasioned by the prick of a needle. 2. By having the injecting 
tube no larger than that of such fine syringes, the puncture in the integument is 
so small that the fluid does not escape. 3. With regard to the formation of ab- 
scess; it is only, for the most part, after repeated injections have been made in 
one place that such happens. One great thing then to avoid it is, to vary as much 
as possible the exact site to be injected, still injecting in the painful part, or to 
cease injecting for a time. The necessarily acid state of the solution of the mor- 
phia (for it must be strong), is certainly another disadvantage; but as irritation 
to the integument appears produced, as little acid as possible ought to be em- 
ployed, and any excess in the solution neutralized by potash. These inconveni- 
ences being obviated as much as possible by the means pointed out, I think such 
advantages as the more rapid introduction of the remedy into the system, the 
avoidance of constitutional (especially nervous) irritation, the greater certainty 
of the effect, and the more concentrated effect of the remedy on the painful part 
ought not to hinder the local treatment of neuralgia from having a fair trial. 

17. Use of Ox-Gall in Hypertropliies. — Dr. Bonorden believes that this re- 
medy is much less employed than it deserves to be. It has usually been employed 
internally only as a resolvent in chronic constipation, and externally in opacities 
of the cornea. He believes it exerts a special effect on the metamorphoses tak- 
ing place in the capillaries ; and for that reason is highly efficacious in all forms 
of hypertrophy. In induration and hypertrophy of the mamma, it exerts a sur- 
prisingly rapid effect, and in this way tumours and indurations have been dis- 
persed by him, which would have been by others removed by the knife. He 
usually employs it in combination with olive oil, adding conium if there is pain, 
and liq. ammon. if there is torpidity. The following formula is very useful : 
R. — Fell, tauri inspiss. '^\\] ; ext. conii mac. ^j ; saponis najronat. ^ij ; olei oliv. 5j. 
M. and rub four times daily. Formerly, he was in the habit of excising hyper- 
trophied tonsils, a practice which he has quite left off since he has been aware of 
the powerful agency of this substance. The gall, rubbed up with water into the 
consistency of an ointment, is applied by means of a good-sized camel's hair 



1859.] 



Medical Pathology and Therapeutics. 



24t 



pencil, twice a day to the entire surface of the tonsil. It causes a slight irrita- 
tion which lasts about half an hour, and is succeeded by an augmented secretion 
of mucus. Unpleasant to the patient at first, he soon gets accustomed to it; 
and indurations which have lasted for years give way under its use in a surpris- 
ingly short time. In all hypertrophic affections of the eye, as hypertrophic 
opacity of the cornea, pannus, and staphyloma, the ox-gall does good service. 
Either the fresh gall may be dropped into the eye several times a day, or it may 
be applied to it with a pencil. In various other hypertrophies, wdiich are acces- 
sible to external applications, we may resort to it, as when they affect the ear, 
mouth, vagina, uterus, or skin. He suggests its employment in hypertrophy of 
the heart, in consequence of the remarkable power it possesses of diminishing 
the action of this organ. — Med. Times and Gaz., Oct. 2, 1858, 'from Berlin Med. 
Zettung, No. 6. 

18. Dropsy treated with Lemons. — Dr. Trinkowsky, a Eussian medical officer, 
reports that in many cases of dropsy, which he has treated within the last seven- 
teen years, he has observed the diuretic operation of lemons in a most remarka- 
ble manner, and even where other remedies had failed. 

He is in the habit of directing that a lemon, freed from its skin, should be cut 
in pieces and sprinkled with sugar, and eaten by the patient. The dose at first 
to be one lemon in the day, gradually increasing the quantity, so that in one of 
his recorded cases eighteen were consumed in twenty-four hours. If pyrosis be 
produced, magnesia is given ; and if the bowels be acted on, the use of lemons 
should be intermitted for a day. — Dublin Hosp. Gaz., Aug. 15, 1858. 

19. Relative Value of the Different Anthelmintics in the Treatment of Tcenia. — 
Dr. Peacock states, that as a general result of his experience, both in public and 
in private practice, he prefers the oil of male fern to all other remedies, and that 
he holds the kousso in very light estimation indeed. It appears that of the hos- 
pital cases respecting which notes have been preserved, the fern oil was given in 
thirty-five. Of these, in sixteen no other remedy had been previously tried, and 
in this group the result was always satisfactory, the animal being expelled in a 
dead or dying state. In seven cases the oil was given after the partially success- 
ful use of kousso, and in all these more of the worm was brought away. In three, 
after partial success by pomegranate bark, the oil brought away other portions 
of the parasite, and in one a like result was obtained after the use of the turpen- 
tine draught. In six cases in which the oil was used, either the result was not 
satisfactory, or the patient did not attend again. The dose of the oil given was 
from half a drachm to a drachm and a half to children, and from a drachm to 
three drachms to adults.' 

The cases in which the kameela was given are seven. In five of these no other 
remedy had been previously tried, and in all these portions of worm (generally 
quite alive) were expelled. In one the expulsion of worm was caused after 
kousso had been tried without effect, and in the fifth, which was under similar 
circumstances, a like negative result followed its use also. In two cases, after 
the successful employment of the kameela, the oil of fern was employed without 
procuring the expulsion of any more of the worm. The dose of kameela pre- 
scribed was from half a drachm to a drachm for children, and from one to three 
drachms to adults. 

It would from the above facts appear that kameela.is more eflScient than kousso, 
but that it must rank as a vermifuge rather than a true vermicide. After the 
fern oil the animal is usually voided dead. An important statement with regard 
to the comparative value of kameela, is made by Mr. Heney Callaway, formerly 
of Finsbury-circus, but now a medical missionary amongst the Zulus. The ka- 

' We are informed that great care is necessary on the part of the dispenser, in 
order to avoid disappointment iu the use of the oil of fern. Its ethereal solution, 
which is by far its best preparation, on standing deposits its resinous principle. 
A prolonged shaking is necessary to secure readmixture. Unless the dispenser 
pay more than usual attention to this matter, the patient is very likely to get a 
dose which is but little more than ether. 



248 



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[Jan. 



meela is the native remedy among the Aborigines ; but in a letter to the Phar- 
maceutical Journal, Mr. Callaway states, that from experience they have learned 
already to put much more confidence in "the white man's dose." The latter 
consisted of turpentine and castor oil, the time-honoured remedy among our- 
selves. We are not able from Dr. Peacock's cases, to institute any comparison 
between turpentine and the fern oil, and can only state that we believe he is sup- 
ported by several other hospital physicians who have given much attention to 
this matter, in maintaining that the latter ought to stand facile princeps among 
our anthelmintic drugs. 

As regards the economics of the question, which are important in hospital arid 
and Union practice, it will, of course, be easily granted that all things considered 
the most efficient remedy will probably in the end prove the cheapest. A dose 
of castor oil and turpentine, undoubtedly, costs far less than any of the others. 
Next to it comes the kousso, which has as rapidly fallen in price as it has in 
general estimation. The kameela is, as yet, rather expensive, though not nearly 
so much so as the fern oil. A full dose of the last costs eight-pence, of the 
kameela about four-pence, of the kousso three-pence, and of the turpentine and 
castor oil not more than three-halfpence. 

Kuchenmeister, in his Manual on Parasites (Sydenham Society's edition), 
writes of the oil of turpentine as follows : " As has already been remarked, the 
touchstone of a remedy for tapeworm is not whether it expels bothriocephalus 
latus or taenia solium, but whether it is also capable of effecting this with t. 
medio-canellata. That oil of turpentine is efficacious in the latter case I can 
prove at any time ; for the finest specimen of taenia med, that I ever saw was 
expelled by it. In general also it acts pretty rapidly. Lastly, it has also the 
advantage that it expels the worm entire." Of the kousso he writes: "For my 
part, I have always been more or less unlucky with this remedy. . . I have 
generally seen the worm expelled in innumerable fragments. ... I have 
never found the head. In one case I detected fragments in the evacuations for 
three months." Professor Martins, of JErlangen, who also has used kousso 
largely, never saw the head brought away. Of the male fern, Kuchenmeister 
states : "This remedy, which will always maintain its renown against the bothrio- 
cephali, appears hardly to maintain its reputation with regard to taenia." The 
kameela he had of course not tried. 

Of the desirability of having the intestinal canal as empty as may be before 
giving anthelmintics, most practitioners are aware. To administer them fasting 
in the morning is usually thought sufficient, but in cases where difficulty has 
been encountered in destroying the animal it maybe well, as an introductory 
measure, to give a sharp purgative. — Med. Times and Gaz., Nov. 6th, 1858. 

20. Hysteric Condition of Joints. — Mr. Baewell read before the Medical 
Society of London (Nov. 15, 1858) a paper on this subject. These affections, 
the author observed, are not rare, especially amongst the more luxurious classes, 
and they have often been mistaken for actual joint diseases, when blisters and 
issues, increasing the evil have been applied, or even more heroic and disastrous 
treatment adopted. It must be confessed that the literature of the subject, and 
the cases collected, are meagre and unsatisfactory, and, therefore, this paper is 
intended to present a concise, yet detailed sketch of the disease, and of some 
new points in its treatment. 

Although in a malady so Protean as hysteria, no short description of invaria- 
ble symptoms can be given, yet two peculiarities may be fixed upon as especially 
characteristic; and these are, the absence of the ordinary signs of inflammation, 
and "anomaly." One may be inclined to add to these symptoms, the hysteric 
condition ; yet, though such condition is present in many cases, it is in others 
Cjuite absent, or so slightly marked as hardly to exceed the ordinary mobility of 
the feminine character. When hysteria breaks out in the paroxysm, it is usually 
sated by that manifestation, and produces no such serious effects as a pseudo 
malady ; indeed, the imitative tendency of hysteria is often checked by a regular 
fit, and a simulated disease may occasionally thus end ; but, in other cases, the 
imitation may continue uninterrupted by any other hysteric symptom, and we 
are then thrown for our diagnosis upon a purely local investigation. Let us first 



1859.] Medical Pathology and Therapeutics. 249 



take the knee, as the more frequently affected joint. The pain is, in some cases, 
so severe as to make the patient hold her leg constantly semi-flexed and immo- 
vable; in other cases, it is so slight that the patient, though complaining, walks 
about. The pain is not in direct, but rather in inverse, ratio with any other 
hysterical symptom. It may be increased at the menstrual period. It is gene- 
rally referred to a spot on either side of the ligamentum patellae, and is increased 
on the slightest touch at this spot, but especially if a piece of the subcutaneous 
fat here situated be pinched. In other cases, the tenderness is spread over a 
larger space, but is always superficial. The articulating surfaces are not tender ; 
they may be forced together, by pressing the foot upward, without producing 
pain. In the severer cases, when the knee is kept fixed, the surgeon, if he 
attempt to change its position, will feel the muscles of the limb thrown into 
strong action. A striking characteristic is the absence of heat about the afiected 
joint — it feels quite as cool, and sometimes, the author is inclined to think, even 
cooler than the other. Swelling, in any marked degree, is absent in cases of 
knee-joint disease ; if measurements be taken, the swelling will be found greater 
than is ordinarily supposed ; but the hysteric knee, when not inflamed by irritant 
treatment, is seldom swollen, and never more than about three-quarters of an 
inch. The swelling is tegumentary merely; the healthy parts may be felt 
beneath. 

When the disease alFects the hip, it is, by a skilful eye, even more easily de- 
tected. When the patient is lying down, the limb is drawn up, the knee bent, 
and there is great superficial tenderness over the whole haunch, hip, and thigh, 
but no pain on pressing the articular surfaces together from the heel upwards ; if 
the joint be not moved, there is no greater heat on that side than on the other. If 
the surgeon, by perseverance, get his patient to stand, he will observe a marked 
twisting of the pelvis, in part an imitation, in part exaggeration, of the position 
assumed in hip disease. The glutei may be felt in strong action, and the nates, 
instead of being flat, on that side are protuberant. Swelling is hardly to be 
measured at the hip, because it is surrounded by muscles whose greater or less 
action must alter the dimensions of the part. That creaking of certain joints 
which sometimes comes on with puberty may gradually become more fixed, till 
it settle down into hysteric joint disease ; therefore, there sometimes accompanies 
this malady, a parchment-like crepitation, which is easily distinguished from the 
crepitus of rheumatic arthritis. Besides these signs, it must be remarked that 
an hysteric patient has not the worn aspect of one whose cartilages are 
ulcerating. 

Now, the peculiarities of hysteric disease impress upon the local complaint a 
quality of unreality which requires some examination. It is not to be supposed 
that these patients willingly deceive their medical attendant, nor that the pain 
complained of has no real existence ; but it is not produced by a local condition 
— the malady is centric, not eccentric. Hysteria has, perhaps, been too much 
regarded as the hete noire of medicine, connected with an obscure and sometimes 
undiscoverable menstrual disorder, and, therefore, to be treated with iron and 
emmenagogues, and such-like medicines. Yet, in truth, though the disease may 
be originally produced by the circumstances and conditions of woman's life, it 
soon becomes independent of uterine action or inaction ; it becomes a neuropathy 
which can be called forth by the feelings and imaginings of the patient, who is 
more or less aware of the power she exercises over her condition, and, believing 
her sufierings real, is yet delighted to direct them by such mental acts. Thus 
the malady must be treated on other principles than such as would follow a mere 
uterine pathology. Great harm is done by the indiscriminate use of steel, ethers, 
aloes, &c., which are often given when a lower diet and more exercise would 
much better cure the disease. If, however, the above view be correct, the treat- 
ment must rather be directed to the cerebral condition which produces the 
neuralgia-like pain, and which has the faculty of swaying the disease by its own 
emotional state ; for it must be evident, from that view, that if this emotional 
state can itself be dominated, the disease will be governed with it ; if the patient's 
faith can be so far mastered as that she shall fully expect to be cured by any 
given proceeding at a certain time, she will be cured by that method at the time 
specified. The author has tried several means whereby, the patients' confidence 



250 



Progress of the Medical Sciences. 



[Jan. 



having been sufficiently gained, he could call away their attention from the part 
affected to some distant spot, in which a disorder working its own cure had been 
artificially produced. Of all such means, a seton seems in most instances the 
best; this is to be made of a single ligature (silk) set in at a distance from the 
affected joint, and embracing only a small portion of skin. The placing of a 
seton is sufficiently painful and like a surgical operation to attract strongly the 
patient's attention, and yet not so much so as to be cruel or greatly repugnant 
to her feelings. Another advantage is that, besides a distinct beginning, it has 
a certain end, which the patient is to watch ; and if she believe, as can well be 
managed, that as the seton works through the skin she will get better, and when 
it comes quite away she will be well, the result is certain to follow her belief. 
Mr. Barwell read several cases which he had thus treated, and quoted in support 
a case in which Mr. Hancock, by giving a patient thus affected chloroform, and 
performing a mock operation, had produced a cure. He observed, in conclusion, 
that the most essential points were — to be quite certain in the diagnosis, to mas- 
ter the confidence of the patient, and to place the seton or other agent at a suf- 
ficient distance from the part affected. — Lancet, Nov. 20, 1858. 

21. Pathology of Rheumatism. — Dr. Francis T. Bond analyzes [Midland 
Quarterly Journal, April and July, 1858) the prevailing doctrines regarding the 
intimate nature of rheumatism, and objects, with regard to the lactic-acid theory, 
which may be said to be the one most generally prevailing at present — 1. That 
lactic acid has not been shown to be in excess in the blood of rheumatic patients ; 
2. That, even supposing it to be present in excess, it would be difficult to trace 
the connection between this circumstance and the exudations in and about the 
different fibrous structures of the body; 3. That other acids being in excess in 
the secretions, and therefore possibly in the blood, they may be as much the cause 
of the phenomena as lactic acid ; 4. That, in regard to the theory attributing the 
disease to suppression of the cutaneous excretions, it is doubtful whether it is 
preceded by greater suppression than the prodromata of all inflammatory diseases 
bring with them ; and 5. That the extreme tendency to sweating which occurs 
during an acute attack of the disease may be much better explained by another 
theory. 

In order to establish a theory of rheumatism, Dr. Bond next analyzes the phe- 
nomena of the disease, and finds that fatigue, exposure to cold, mental emotions, 
or some other depressing agent, exercise a paramount influence in its production ; 
febrile symptoms making their first appearance, followed by local affections in 
some fibrous tissue. A hyperinotic condition of the blood exists from the first, 
and the excessive fibrin having a special affinity for the fibrous structure, is spe- 
cially deposited in and about them; hence the joints and the valves of the heart 
become the chief seats of the local affection. The preference shown in different 
cases for particular joints depends upon their greater weakness, or upon their 
labouring under some abnormal condition, upon the principle enunciated by Mr. 
Paget, that the depressed nutrition of a joint makes it more liable than any other 
part to be the seat of inflammation excited by the diseased blood. Dr. Bond's 
theory, then, reverses the order in which the different constituents of the diseases 
are commonly supposed to stand. Instead of regarding the hyperinosis merely 
as an effect of the reaction of the local disease upon the system at large, he con- 
siders it to be the primary source of the exudation, the causative agent of the 
latter, without which it could never exist. The increase in the urinary and cuta- 
neous secretions, and the greater amount of urea, uric acid, lactic, phosphoric, 
and other acids in them, the author attributes to the metamorphosis of the fibrin ; 
these substances being the products of the degradation of fibrinous matter, " the 
relations of urea and uric acid to highly nitrogenized matters — as exhibited by 
the experiments of Lehmann, by the recent manufacture of urea by oxidizing 
albuminous substances by M. Bechamp, and by the general excess of these ex- 
creta in the hyperinotic states of the blood, combined with that of lactic acid, to 
the muscular juice as determined by the researches of Liebig — amply corroborate 
this statement as far as these three bodies are concerned; the others, from the 
smallness of their amount, may be put out of consideration." 

Dr. Bond considers the sources of an excess of fibrin in the system to fall under 



1850.] 



Medical Pathology and Therapeutics. 



251 



three heads : 1. As a result of imperfect primary assimilation ; 2. As a result of 
a metamorphic process, normal in nature, but extreme in amount; 3. As a result 
of defective elimination of the fibrin by the excretory processes provided for the 
purpose. 

Having said thus much, we must refer our readers for the conclusions which 
the author draws as to treatment to the paper itself; we will merely add that his 
theory possesses a great resemblance to that propounded by Mr. Toynbee, a short 
time back, at the Medico-Chirurgical Society, shortly after the publication of the 
first part of Dr. Bond's paper. — Brit, and For. Med.-Chir. Rev., Oct., 1858. 

22. Bronzed-skin Cachexia, with Congenital Absence of the Supra-renal Cap- 
sules. — Mr. J. K. Spender records [British Medical Journ., Sept. 11, 1858) an 
example of this. The subject of it was a female, 53 years of age. " She had 
been for some time ' out of health' — ailing — suffering from something difficult to 
define, and out of the category of ordinary nosologies. She looked very pale, 
the pallor having that dark earthy tint which is ordinarily associated with the 
existence of malignant disease. When she sat down, she stooped forward like a 
very aged person, from physical inability to sustain herself upright ; and her las- 
situde and exhaustion appeared to be extreme. No pain was complained of, but 
she had lately suffered from diarrhoea, although this was not of sufficiently long 
continuance, nor of sufficient severity, to explain the aggravated spangemia. Her 
health, until two months previously, had always been good ; and she had appa- 
rently been one of those persons who, by 'never having known a day's illness,' 
are said by a great humourist to miss one of the finest disciplines of life." 

The treatment was simple, and did not influence the progress of the disease. 

^' The post-mortem examination revealed the entire absence of the supra-renal 
capsules. The kidneys were healthy ; but there was a remarkably anaemic con- 
dition of the whole mucous membrane of the alimentary canal — a point to which 
attention was first directed by Dr. Simpson. Black pigment was accumulated 
to a considerable extent in the mesenteric and bronchial glands. The latter 
were so swollen with pigment that they appeared like tough inky tumours, thus 
literally realizing Rokitansky's words (vol. iv. p. 393, Syd. Soc. edit.). Black 
pigment was also noticed in the parenchyma of the lungs. The other thoracic 
and abdominal organs were healthy. The cavity of the head was not examined. 
The tegumentary discoloration was tolerably uniform, and had a metallic shining 
character by reflected light. Over the flexures of the great joints, the dark 
tinge was much increased." 

23. Bronzed Skin and Healths/ Supra-renal Capsules. — Dr. Harley showed 
to the Pathological Society of London different parts of discoloured skin, and 
also the healthy capsules, which were taken from a man, aged sixty-six, who 
died in University College Hospital. The patient was admitted into the hos- 
pital, under the care of Dr. Parkes, a month before his death. At the time of 
his admission he presented a curious appearance, being more like a half-caste 
than a native of a temperate climate. The whole body, except the lower ex- 
tremities and a few isolated patches on the abdomen, was of a dark bronze 
colour, the darkest parts being about the head and neck. His history was, that 
seven years ago he had a five-weeks' attack of jaundice, from which he perfectly 
recovered. Three or four months afterwards he observed a change taking place 
in the colour of his skin ; some parts seemed to become whiter, others darker. 
The dark places gradually increased in size, and at the end of six months had 
extended to nearly the degree they presented on his admission. During the last 
three or four months of his life he had become gradually weaker, lost flesh, and 
liad little or no inclination for food. His bowels, too, were irregular. In fact, 
the case presented the signs and symptoms of Addison's disease. On post- 
mortem examination, however, the capsules were found peifectly healthy in 
every respect, both by naked eye and microscopical examination. The perito- 
neum, as well as the rete mucosum of the skin, contained pigmentary matter. 
The man died from ascites, the result of a diseased liver. — Lancet, Nov. 27, 1858^ 



252 



Progress op the Medical Sciences. 



[Jan. 



24. Intestines of^ a Pig, which, for six weeks hefore death, had been fed with 
" Typhoid Dejections^ — Dr. Murchison exhibited these to the Pathological 
Society of London, and observed that although it was generally admitted that 
the true typhus fever is eminently contagious, many still entertained doubts as 
to the contagious nature of the so-called " typhoid fever ;" yet it was difficult to 
explain, in any other way, the facts which had been adduced by Bretonneau, 
Gendron, Piedvache, and others. Some observers, and more particularly Dr. 
Budd, of Bristol, and the late Dr. Snow, had thought that typhoid fever was 
propagated by the dejections from the bowels. Without questioning the validity 
of this supposition, Dr. Murchison expressed his belief that many of the facts 
which had been urged in its support might be explained on the hypothesis of a 
spontaneous origin of the fever from the putrid emanations from the drains, 
which had been thought merely to convey the poison. All those who had con- 
sidered that the fever might be communicated by the dejections had been strong 
opponents of the possibility of its spontaneous origin. It was obviously of great 
importance, both in a medical and a sanitary point of view, to determine whether 
fever might be communicated in the manner just alluded to. The experiment 
had been undertaken in order to throw some light upon this question ; and its 
results were offered simply for what the results of one experiment might be 
worth. A pig had been selected for the experiment for the following reasons : 
1. Because in its diet it approached most nearly to man ; and it was thought 
that less difficulty would be encountered in making it submit to the experiment 
than with other animals. 2. There were few or no animals in which the struc- 
tures that became specially diseased in typhoid fever, viz, Peyer's patches, were 
so well developed. 3. Because there was evidence that the pig was liable to 
typhoid fever. Cases of the disease, in this animal, in which the characteristic 
lesions had been found after death, have been described by Falke and other 
writers on veterinary medicine. The pig selected was between three and four 
months old. Care was taken that the dejections were obtained from typhoid 
patients in whom they presented the light ochrey colour peculiar to the disease 
in the most marked degree ; they were mixed up with barley-meal and other 
articles of food. The first was given on Sept. 9th, 1858. For the first three 
weeks one was given every day, or every second or third day. During the next 
fortnight, two or three were given every day ; and, during the last week, one 
every second day. They were eaten greedily. On two different occasions, dur- 
ing the first fortnight, the animal had slight diarrhoea, lasting for twelve hours, 
and its ears felt rather hot ; but these symptoms speedily subsided. With these 
exceptions, the animal exhibited no abnormal symptoms ; its stools were of nor- 
mal consistence, and it increased greatly in weight and size, as was shown by 
measurements taken at the commencement and at the termination of the experi- 
ment. On Oct. 23d it was killed, and its body opened. There was abundance 
of subcutaneous fat, and the muscular tissue appeared healthy in every respect 
The intestines throughout were healthy. There was not the slightest trace of 
any recent or old ulceration anywhere, nor of any thickening or alteration of 
Peyer's patches, or of the solitary glands. The mesenteric glands were not en- 
larged. — Ibid. 

25. On a peculiar Black or Blue partial Coloration of the Skin, luhich is 
sometimes observed in Women, particularly round the Eyelids. By Leroy De 
Mericourt. Besides the four cases of this singular affection described by Neli- 
gan, M. quotes one case described by Yonge in 1709. She was a girl of 16, na- 
tive of Portsmouth, never menstruated, and black coloration gradually disap- 
peared in six months; and another described by Billard in 1813, also a girl of 
16, whose face, neck, and upper part of the breast, particularly the brow, alae 
nasi, and round the mouth, presented a beautiful blue colour, which could be 
wiped off with a towel, and coloured the white linen. She had menstruated re- 
gularly for two years ; and from that date had observed the blue coloration round 
her eyes, which disappeared in the open air, but speedily returned, so soon as 
she began to work in a warm close room. After a year, the blue coloration 
spread over her face, neck, and belly, and no longer disappeared in the open air. 
Subject to a dry cough, she occasionally expectorated a little blood, especially 



1859.] Medical Pathology and Therapeutics. 



253 



about her menstrual period, after this had passed, accompanied by vomiting and 
expectoration of blood; she was paler, breathed more freely, and the blue colora- 
tion was almost gone ; increased heat and vascular excitement brought out the 
colour stronger ; the blue colour was tested by various re-agents ; and, as amongst 
those which neutralized the colour, bicarbonate of soda seemed the least hurtful, 
it was given internally, and in twelve days the coloration was once more restricted 
to the circumference of the eye, the brow, and the alae nasi. M. has himself ob- 
served in Brest no fewer than five cases ; the first three he relates summarily, as 
they occurred some years ago, and the phenomena were incompletely manifested. 
The respective individuals were from seventeen to twenty years of age, previous 
health in two of them normal, in the third dysmenorrhoea, hysteria, and megrim 
co-existed. Twice the dark coloration came on, after sudden suppression of the 
menses. In one case, fainting, headache, palpitation, and oppressed breathing, 
were the immediate results of the suppression, the coloration beginning two days 
subsequently on the upper and lower eyelids, other dark stains likewise making 
their appearance on various parts of the body. The dark colour was paler in 
the morning, and became darker after exposure to any excitement or high tem- 
perature. After two years her catamenia recurred ; the dark colour, however, 
remained, withstanding the effects of marriage and several confinements, expe- 
riencing, however, a perceptible diminution during lactation. Since then the 
colour has become markedly paler, although the menses are still incomplete. In 
the second case, there was also markedly less colour in the morning, which could 
also at such times be partly wiped off", but speedily recurred ; in this case, as 
well as in the third, the colour remained during pregnancy. The fourth case 
was a newly married woman, aged twenty-two, who first menstruated in her se- 
venteenth year, and a year after, while menstruating, fell into the water up to her 
waist, whereby the menses were suddenly suppressed, and she was seized with 
headache, palpitation, oppressed breathing, and colic pains, and also expecto- 
rated blood several times. Four days subsequently, she remarked a dark colora- 
tion of the lower lids, which speedily increased in extent and intensity. Four 
months after the menses recurred, the black colour remaining, however, much 
the same, paler in the morning, more remarkable after excitement or exposure to 
high temperature ; lately, however, it has become much less. The fifth case was 
a brunette child's-maid, aged twenty, who menstruated first at seventeen, and had 
been hitherto in good health. About two months ago, three days after normal 
menstruation, she remarked a dull blue coloration of both lower eyelids, which 
had next day assumed a darker tint, like china ink, and extended down the cheeks. 
Examination with a magnifying glass showed that, as in Neligan's case, the co- 
loration depended on a multitude of dark points, wiping with a towel stained 
the latter; but neither wiping nor washing sufficed to remove the colour. This 
coloration, according to M., consists in a pigment deposit on the surface of the 
epidermis. Neligan and Hebra have supposed, from the punctuated appearance 
of the coloration, that its seat was in the sebaceous follicles. M. rejects this, 
because any connection between menstruation and these follicles is unknown, 
while pigmentation stands in acknowledged relation to many uterine conditions, 
as pregnancy, for example. M. particularly refers to the evanescence and muta- 
bility of the coloration in several cases as incompatible with this theory of its 
origin, and without speaking positively, seems to regard the punctuated appear- 
ance as more probably depending on pigmental alterations of the openings of the 
perspiratory ducts. The eyelids are the chief seat of this coloration, partly be- 
cause of the fineness of their integuments, partly because of the acknowledged 
sympathy of the eye with the sexual organs. M. considers that Neligan's de- 
finition, " Stearrhoea nigricans" is erroneous and premature, and that a circum- 
locutory title is to be preferred, until more is known regarding the nature of the 
affection. From the ten cases already described, M. draws the following conclu- 
sion : Etiology. The individuals affected were from sixteen to twenty-two years 
old ; two were sixteen ; eight had not yet menstruated ; the disease always com- 
menced in the unmarried state. In eight cases there were either dysmenor- 
rhoea or amenorrhcea ; only in one case was menstruation unaffected ; thrice 
there was sudden suppression of the menses (twice after exposure to cold, once 
after mental excitement). Nine cases occurred in towns situate near the sea, 
No. LXXIIL— Jan. 1859. It 



254 



Progress of the Medical Sciences. 



[Jan. 



five of these in Brest. Two patients were of fair complexion (Blondinen) . The 
eruption of the disease was usually sudden, yet it always took some days to 
reach its height. The shortest duration of the disease has been three months ; 
another case has already lasted seven years. In tedious cases, the coloration 
endures in spite of the return of the menses, or parturition itself, though both 
bring about variations in it. In one case nursing was beneficial. Its disappear- 
ance was never sudden, always gradual. The therapeutics must always have 
respect to the apparent prime cause, anormal menstruation ; the due regulation of 
that is sometimes followed by disappearance of the coloration, always by a di- 
minution of its tint. — Ed. Med. Journ., Nov. 1858, from Archiv. Gen., 1857. 

26. Lesions and Pathological Phenomena caused hy the Presence of Lumbrici 
in the Biliary Ducts. — Dr. E. Bonfils, after combating Cruveilhier's opinion that 
intestinal worms can be introduced into the biliary ducts only after death or dur- 
ing the death struggle, analyzes the 23 cases which he has collected, in which 
lumbrici were discovered in the ductus communis choledochus, in the gall-bladder, 
or in the hepatic duct ; in 2 cases the lumbrici were perfectly fresh and still living ; 
in 1 the worm was dead and slightly altered, was of a pure white, and softened ; 
in 1, reported by M. Forget, a lumbricus occupying the ductus communis and the 
ductus hepaticus was perfectly fresh, while another occupying an abscess in the 
right lobe of the liver was softened and macerated, evidently having been long 
dead ; in 1 case a lumbricus formed the nucleus of a biliary calculus. The symp- 
toms varied much in the difierent cases, but the author considers that the presence 
of the following circumstances justifies the conclusion that we have to deal with 
the presence of a lumbricus in the biliary ducts : the sudden appearance of mor- 
bid phenomena, without appreciable moral or physical causes, of considerable 
intensity, characterized by very violent pain, combined with deep colour of the 
skin, vomiting, &c., similar to the symptoms accompanying calculus in the biliary 
passages ; a rapid disappearance of all phenomena on the discharge of the worm ; 
the concurrence of these symptoms, unassociated with general colicky pains (co- 
liques exterieures), are regarded by the author as indicative of a lumbricus being 
the foreign body which has entered the biliary ducts, and having thus arrested 
the passage of the bile. — Brit, and For. Med.-Chir. Rev., Oct., 1858, from Arch. 
Genirales, June, 1858. 

27. Development of the Larvae of Dipterce in the Frontal Sinuses and Nasal 
Fossae, of Man, at Cayenne. By 0. Coquerel, Surgeon to the Imperial Marine. 
— Five cases are reported by Drs. St. Pair and Chapuis, the medical officers at- 
tached to the Convict Hospital at Cayenne, in which the most violent symptoms, 
followed in three by death, were produced by the immigration and subsequent 
■multiplication of a diptera into the nasal and frontal cavities. In most of the 
cases several hundred larvae were evacuated by ulceration and necrosis of parts 
investing the cavities. The cases all present symptoms so closely resembling one 
another, that it will suffice to give one in detail. 

Goujon, a watchman, was admitted into the Hospital of Cayenne on the 5th of 
September, 1855, complaining of intense pain in the supra-orbital region and in 
the right side of the face ; there was neither tumefaction nor change of colour. 
On the following day there was severe headache, the other symptoms remaining. 
On the 8th of September the right side of the face was swollen, and a sanguino- 
lent fluid was discharged from the nasal fossfe. On the 9th the whole face pre- 
sented an erysipelatous swelling, with oedema of the eyelids and of the upper lip ; 
the skin was stretched, hot, and shining ; on the bridge of the nose a tumour of 
a purple hue appeared, from which, on being incised, black fetid blood escaped. 
The patient having sat down, a larva was discharged by the nose. An injection 
of warm water into the nasal fossae brought away about a dozen larvae resembling 
the first. Delirium ensued ; the head was bent back ; the pulse hard and quick ; 
the skin hot, with much thirst ; the swelling of the face extended to the forehead, 
while the tumefaction of the eyelids entirely concealed the ball of the eye. Several 
injections of a solution of chloride of soda were made, and about twenty larvaj 
removed with the current. On the night of the 9th the symptoms previously men- 
tioned became more severe; local and general bloodletting, revulsive remedies 



1859.] 



Surgery. 



255 



applied to the intestinal tube and the extremities, cold affusion to the head, and 
injections into the nares, failed to produce any amelioration. . Death ensued on 
the 10th of September, six days after admission. 

Autopsy. — The tissues covering the nasal bones were gangrenous, and dis- 
charged a black and fetid liquid. The mucous membrane of the nasal fossae was 
inflamed in its whole extent ; about ten more larvae were found crawling on the 
pituitary membrane. On a level with the middle passage the mucous membrane 
was red, thick, and softened. On opening the cranium, the meninges were found 
of a dark red, gorged with blood, which was particularly the case at the base of 
the brain. The ventricles contained a sanguinolent fluid; the brain, on incision, 
showed a large number of red dots. 

In his remarks on the treatment. Dr. Coquerel lays great stress on the import- 
ance of injections, though he admits the extreme difficulty of removing the ani- 
mals, especially after inflammation of the mucous membrane has set in ; it does 
not appear that the plan of trephining the frontal sinuses, which he recommends, 
has been adopted. He advises the most energetic antiphlogistic treatment to be 
employed at the same time, a proceeding for which we can see no warranty, so 
long as the irritant cause is not dislodged. 

None of the patients know how the larvfe were introduced, though it is probable 
that they were the issue of eggs deposited in the nasal fossae. After being warned 
to prevent the entrance of insects, one of the convicts caught a fly which was 
about to enter, and it appears that this was a member of the tribe Lucilia, be- 
longing to the order Dipterae. Dr. Coquerel gives to the Cayenne variety the name 
Lucilia Homini-Vorax, and describes it thus: Length, nine millimetres (0.35 
inch) ; yellow palpae; the head and mandibles of a fallow colour, covered with a 
golden-yellow down ; a very large head, broader at its base than at its junction 
with the thorax ; the latter of a deep blue, with a purple reflex ; on each side of 
the thorax, and in its middle, a transverse band of blackish blue, the middle one 
being narrower than the others, and separated from them by a golden-yellow line 
of little brilliancy, and presenting a few purple reflexes. The abdomen was of the 
colour of the thorax, with purple reflexes accompanying each segment. The feet 
were black, the wings transparent, slightly opaque, especially towards the base, 
with black veins. 

Dr. Coquerel does not regard the insect in question as a parasite, but considers 
the development of the larvae in the site in which they were found as purely acci- 
dental. He quotes several analogous cases to those forming the subject matter 
of this paper, from authors who had observed similar occurrences in Europe. — 
Brit, and For. Med.-Chir. Rev., Oct., 1858, from Archives Generales, May, 1858. 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

28. On Clironic Infiammation of the Articular Extremity of the Bones. — Mr. 
T. Bryant, in a paper read before the Medical Society of London (Oct. 18th), 
commenced by stating that, under the name of chronic inflammation of the arti- 
cular extremity of the bones, he would venture to call the attention of the Society 
to a large class of interesting diseases, which, in their origin, are seated exclu- 
sively in the bones, but which, from their proximity to the joint, are almost 
always followed by disease of the articulation, unless arrested in an early stage. 
It had been described by authors under different names, and is now generally 
known by the term strumous or scrofulous disease of a joint; but he could not 
for one moment doubt that the majority of the cases which are described by sur- 
geons under that name depend upon a chronic inflammation in the bone. The 
disease is, in its origin and progress, inflammatory, and by early treatment may 
be arrested. The pathological conditions found upon examination are those 
which an inflammatory process will produce, and it is quite exceptional to find 
in any bone that yellow, cheesy, material which pathologists so well knew as 



256 



Progress of the Medical Sciences. 



[Jan. 



strumous deposit ; he did not deny that such a deposit may be occasionally pre- 
sent, but the cases in which it is found are so rare, that we may fairly regard 
such a specimen as a pathological curiosity. If, then, we confine the term stru- 
mous disease of a bone, as he (Mr. Bryant) believed we should, to such instances 
only where such a deposit is present, we shall, as surgeons, seldom have occasion 
to employ it. He then went on to describe the pathological changes which are 
visible in such cases ; how, in the earliest condition, simple vascularity of the bone 
is the principal morbid condition associated with the presence of pinkish serum 
in its cancellated portion, which is much enlarged and easily broken down on 
pressure, from the loss of its earthy constituents. In its more advanced stage, 
the bone will be found much enlarged, the columns radiating from the shaft in a 
palm-like fashion, as if they had been spread out from downward pressure. He 
stated that if the inflammatory processes were of a tolerably healthy character, 
parts of the bone would appear denser and more indurated than the remainder ; 
but that more frequently suppuration and death of the bone was the result, and 
that a small or large sequestrum would be seen. The denser portion of the bone 
would also appear thinner than natural, and the articulating surfaces more vas- 
cular. In more advanced cases, portions would be found loose, and lying in the 
joint, having been like a slough thrown off, the denser portions of bone dying 
more rapidly than the cancellated. The author then went on to show how the 
cartilages would be first affected when the disease had extended to the articular 
surfaces of the bone, and that in advanced disease they would be either thrown 
off, and found lying loosely upon the bone, or, in more chronic cases, to have 
entirely disappeared. He stated that the disease, having involved the articular 
cartilages, would soon spread to the synovial membrane, and that effusion into 
the joint would then appear; the symptoms being very acute when any portion 
of the bone had died and been discharged into the joint ; in that case, rapid dis- 
organization of the joint would be the result. Mr. Bryant then remarked upon 
the chronic character of this disease, and that it might take months, or even 
years, before the final destruction of the joint took place; but that, unless ar- 
rested, such a termination must, sooner or later, be observed. He then pro- 
ceeded to the consideration of the symptoms by which such changes can be diag- 
nosed, and dwelt upon the importance of observing the earliest conditions of this 
serious malady, for it is only in an early stage that much hope can be entertained 
of arresting its progress. The earliest symptom, which will generally call atten- 
tion to the part, is some slight pain or aching, increased by pressure over some 
portion of the bone, and it is most frequent in delicate and strumous children. 
In more advanced cases, an evident enlargement, or dilatation, of the bone will 
be observed, accompanied with stiffness upon movement, and increased pain. He 
then described how, as the disease advances, the cellular tissue external to the 
joint becomes involved, as known by thickening, and that when the disease had 
spread to the cartilages and synovial membrane, the pain became much greater, 
associated with inability to move the joint without great torture, and attended 
with all the local and constitutional effects of an acute synovitis. Suppuration 
sooner or later appears, and abscesses open in all parts of the joint, the charac- 
ter of the disease being well declared in the total destruction of the articulation. 
The author then briefly alluded to the symptoms as displayed in different joints, 
and remarked that in delicate strumous children, the earliest complaint of pain 
or aching of a joint should not be disregarded, and that if it is at all lasting, the 
earliest stage of this chronic inflammatory condition of the bone should be sus- 
pected. He stated that parents are too apt to treat the complaints of children, 
particularly of joints, as "growing pains," and that on this account frequently 
the earliest symptoms of this severe disease are overlooked, to the sacrifice of 
the child's joint, or even life. In considering the treatment, the author stated 
that there were two principal facts which we should always remember — first, 
that the disease was inflammatory in its origin and in its progress ; and secondly, 
that it was almost always found in subjects of a weakly constitution and of 
small power. The first point, then, was to correct, if possible, the disposition to 
disease ; to supply power to the patient to resist the morbid inflammatory pro- 
cess and to overcome its effects. Tonics then became valuable remedies, in any 
orm that might suit the patient ; he preferred iron, in the form of the syrup of 



1859.] 



Surgery. 



25T 



the iodide, or the phosphate combined with the phosphate of lime. Cod-liver oil 
was also a good tonic, and might be given at the same time. Good diet and 
bracing air were also recommended, and, in fact, all general considerations should 
be employed to improve the health and weakly powers. With respect to local 
treatment, Mr. Bryant stated that rest was an absolute necessity; that no move- 
ment or pressure upon the joint by standing should be allowed upon any con- 
sideration; and that, in the earliest cases, this local treatment, combined with 
the constitutional, was frequently sufficient; that when pain was great, leeching 
was of vast benefit, and hot or cold applications, according to the relief they 
conferred. When the cellular tissue became involved, the author believed that 
mercurial strapping was a valuable remedy, and that splints were also required 
to preserve perfect rest. In recent cases, where symptoms clearly indicate dis- 
ease of the joint, he strongly advised the use of mild mercurials, in the form of 
the bichloride, or gray powder, combined with tonics ; and stated that under its 
use, with rest and other constitutional remedies, a speedy cure may often be ob- 
tained. When by suppuration of the part the cartilages had clearly become de- 
stroyed, and all hope of restoration had passed away, it should be the object of 
the surgeon to obtain an anchylosis of the joint; and this might very frequently 
be accomplished by preserving perfect rest and immobility of the part by splints 
and strapping, and attending at the same time to the constitutional treatment of 
the patient ; but this end could only be obtained by great care and much patience, 
on the part both of the surgeon and his patient. The author then went on to 
consider the subject of operative interference in these cases, and expressed an 
opinion that when necrosed bone was present, and perfect disorganization of the 
joint had taken place, if the part diseased should be the shoulder and elbow, there 
was no doubt that excision of the joint was the right operation to be performed, 
as perfect success might there generally be expected, and even partial use was 
better than the loss of a limb ; but that when the hip and knee-joints were the 
diseased parts, it was impossible to speak of the operation of excision in the same 
positive and unqualified terms. He believed that when it was possible to diagnose 
the existence of necrosed bone, the joint being as a result already disorganized, 
and if the surgeon was tolerably certain about being able to remove it, the ope- 
ration of excision of the diseased portion was certainly the correct treatment, if 
other general considerations were not opposed to such a practice ; but in the 
hip-joint such a diagnosis was seldom possible, and the removal of a portion only 
was quite useless, for the part would heal up partly, only again to open, and be 
followed by all the symptoms which had previously existed. He believed that 
the only cases in which removal of the head of the femur was advisable, were those 
in which the bone was dislocated upon the dorsum, and necrotic, and which by 
its presence was keeping up profuse suppuration and constitutional irritation ; 
but he thought that such cases could hardly be regarded as cases of excision of 
a joint, but should be classified more naturally with the operations for caries or 
necrosis. When discussing the question of operation as applied to the knee- 
joint, he believed that when the case was a good one for excision — that is, when 
the disease was chiefly confined to the articular facets of the joint, and the powers 
of the patient were good — it might be confidently asserted that there was gene- 
rally a fair chance of obtaining an anchylosed limb, and that the operation of 
excision should then never be performed. In other cases, where the disease was 
more extensive, involving a large portion of the articular extremities of the bones, 
and where the powers of the patient were bad, the chances of success by ex- 
cision became small, and amputation had then better be resorted to. There 
might be some intermediate cases, where the disease was in the head of bones, 
and where that disease might be removed ; where the chances of recovery if left 
to nature were slight — for she might be unable to throw off", or get rid of, the 
necrosed or carious bone — and where the powers of the patient were tolerably 
good; in such, if the surgeon could, remove the bone which was keeping up, by 
its presence, the disease in the joint, and was thus preventing its recovery, the 
operation of excision might be pronounced of value. The author had no doubt 
that limbs were now saved more frequently than of old by means of excision, but 
there was also no doubt that many of these were useless, if not absolutely in- 
jurious and in the way; and although he would not wish the Society to believe 



258 Progress or the Medical Sciences. [Jan. 



that lie was at all an opponent to wliat is called conservative surgery, still mere 
conservation must be injurious, if it were not associated with practical tendencies ; 
and unless a limb could be restored sufficiently to enable its owner to pursue his 
duties or his occupation, its absence would be less injurious, and amputation had 
better be performed at once. The author stated that he might have quoted nu- 
merous cases, to illustrate the different points brought forward, from his notes of 
two thousand cases of injuries and diseases of the joints which he had in his pos- 
session ; but he felt sure that the experience of those surgeons who were present 
would supply the deficiency. He concluded by stating that he had given, as 
briefly as possible, the results of inquiries which he had been pursuing for many 
years ; and that if he had been able to place a large and serious class of cases in 
their proper position in our surgical pathology, his end had been obtained, and 
he trusted that the time of the Society had not been taken up in vain. 

29. A rare Form of Fracture of the Clavicle. By M. Eobeet. — In the adult, 
fractures of the clavicle are almost always oblique, the periosteum being torn and 
the fragments displaced. Sometimes, however, in the adult, but oftener in the 
child, the fracture may be transverse, without laceration of the periosteum or dis- 
placement. This was the case with a miserable-looking lad, aged sixteen, brought 
to M. Eobert at the H6tel Dieu, his left clavicle having come in contact with a 
table during a fall. There was no displacement, and the bone presented quite its 
normal appearance, there being neither ecchymosis, projection, nor depression. 
On passing the fingers along it, however, with a gentle pressure, a painful spot, 
with a slight mobility at it, was felt; and whenever the long thin bones — such as 
the fibula, ribs, or clavicle — have been exposed to violence, and no deformity is 
observed, pain limited to a very small portion of their course is quite sufficient to 
give rise to the belief in the existence of a fracture. To search here for crepi- 
tation would only rupture the periosteum still entire, and thus increase the gra- 
vity of the case. All that was required was to keep the arm against the chest, 
and caution the patient against using it — a caution of importance, for there being 
no displacement and but little pain, the patient, believing the bone not broken, 
might easily employ the limb dangerously. 

In a few days the tissue surrounding the fractured point became inflamed, and 
the swollen periosteum formed a projecting ring uniting and maintaining the frag- 
ments in contact; confirming entirely the diagnosis derived from the localized 
pain and slight mobility first observed. Cases come to the hospital a week or a 
fortnight after the accident, exhibiting merely this circular ring, the nature of 
which may be yet more difiicult to understand, as the patients have often forgot- 
ten that a fall or a blow has taken place. It is well to be aware of this, as the 
projection may be mistaken for a periostitis or an exostosis. It is easily ascer- 
tained to be a ring constituting a provisional callus, by imparting to the bone 
movements which are easily perceived, the ring being as yet only in its fibrous or 
cartilaginous condition. It gradually ossifies, and is replaced by a small definitive 
callus. Ordinary fractures of the clavicle are hardly ever accompanied by a pro- 
visional callus, this only being found when the periosteum is preserved entire. — 
Brit, and For. Med.-Cliir. Rev., Oct., 1858, from L' Union Medicale, No. 79. 

30. Dislocation of the Rigid Femur on the inferior part of the Dorsum Bii — 
seven weeks' duration ; Reduction hy Dr. Reid's Plan. — Mr. W. J. Square re- 
cords {Med. Times and Gaz.,) a case of this, which is interesting from the luxa- 
tion being readily reduced by manipulation after failure by the use of pulleys and 
chloroform. 

The subject of it was a farm-labourer, 30 years of age ; the dislocation was the 
result of a fall in wrestling, his antagonist falling on him. 

" Chloroform used. Anaesthesia imperfect. The patient being placed on his 
back on a convenient table, the pulleys were applied, and extension kept up for 
twenty-five minutes. On slackening them, it was at first thought that the head 
of the bone was in the acetabulum, but during examination it slipped with a sort 
of snap into its old position. The pulleys being reapplied, extension was con- 
tinued for twenty-five minutes longer, with the advantage of more complete 
anaesthesia, but reduction was not accomplished. 



1859.] 



Surgery. 



259 



" Mr, Whipple now suggested to me the employment of Dr. Reid's (U. S.) 
mode of reduction of the femur on the dorsum ilii, which I at once commenced. 

" The patient being still imperfectly under the influence of chloroform, I placed 
him on his back, grasped his ankle with my right hand, and his knee with my 
left. 

" I then bent the leg at right angles with the thigh, and the thigh with the 
body, slowly and firmly pressed the knee and dislocated femur upwards and in- 
wards towards the patient's face, and then swept it outwards and downwards in 
a circular direction along the right side of the body. While this last movement 
of rotation was in progress, the head of the femur slipped with a jerk into its 
socket. 

" The limb instead of being directed inwards was now rotated outwards, with 
apparent elongation. 

" The thighs being bandaged together, with an interposed pad, the patient was 
placed in bed, 

" April 15, Can walk without pain or lameness. The lower extremities are of 
equal length, and their axes alike. Some atrophy of the muscles about the hip- 
joint continues, and in walking he feels weaker than before the accident." 

31. Dislocation of the Forearm outtuards. — The following interesting case of 
this uncommon form of dislocation is recorded in the Dublin Hospital Gazette 
(Aug. 15, 1858) :— 

"John Reilley, aged twelve years, a tine, strong, healthy-looking boy, was 
brought to the Meath Hospital on the 22d July, 1858, immediately after having 
fallen from a high wall, on the top of which he had been creeping all-fours. He 
unfortunately placed his hand on a loose brick, which gave way, and caused him 
to be precipitated. On admission, he complained of very severe pain in the right 
elbow, and, his clothes being removed, the nature of the remedy became mani- 
fest, from the prominence outside the external condyle of the humerus. The 
head of the radius was well marked, and the articulating surface of the humerus 
could be distinctly felt below and on the inside. An attempt was at first made 
to reduce the luxation in the same manner as one of the forearm backwards, by 
flexing the limb, whilst the humeral extremity of the forearm is drawn down- 
wards, or, as Sir A. Cooper says, 'bending the arm over the knee, without attend- 
ing to the direction, outwards or inwards.' By this manoeuvre, the muscles were 
put into violent action, and, as the effort gave a great deal of pain, chloroform 
was called for, but, before it could be brought, the reduction was effected by 
pressing the head of the radius downwards, forwards, and inwards, the internal 
condyle of the humerus being at the same moment pushed in the opposite direc- 
tion. The arm was then placed on a cushion, and a cold evaporating lotion kept 
constantly applied. No great amount of inflammatory action ensued; and, 
although some trifling swelling of the joint remained, still the boy was well 
enough to leave the hospital on the third day after the accident, 

"These are not dislocations in the reduction of which much difficulty is to be 
expected, when recently seen; but, in the case just stated, the facility with 
which it was accomplished was most remarkable and satisfactory, when the pres- 
sure was made across the axis of the joint; proving that a slight amount of force 
will often accomplish the desired replacement of a bone, when made in the pro- 
per direction." 

32. Displacement of the Coccyx sideways. By Roeser. — " A corpulent wo- 
man, aged thirty-six, fell from a table on a chair, so that its back came right 
between her thighs. She instantly felt severe pain in the coccyx, but continued 
able to move about till evening, sitting increasing the pain very much. In the 
evening the pain was so great, extending up the spine, that she was obliged to 
go to bed, and soon after could neither turn nor rise up. After a painful night, 
R, found this otherwise blooming woman quite immovable, with distorted fea- 
tures ; she complained of violent pain in the coccyx, and a painful tensive draw- 
ing feeling from below, up to the neck, which also extended down the arm. She 
could move the forearm a little. The slightest motion of the body or head to 
one side was impossible, and still more so sitting up in bed ; confused head- 



260 



Progress of the Medical Sciences. 



[Jan. 



ache, and some mental disturbance, were also present. She made no com- 
plaints of her lower extremities, nor of her arms, and urinated without difficulty. 
After placing her on her right side, a small swelling, the size of a hazel-nut, was 
felt near the notch of the buttocks next the left ischium, which, on closer exa- 
mination, proved to be the coccyx separated from the sacrum, and forced from 
the mesian line towards the left ascending ramus of the ischium. The obtuse 
end of the sacrum could easily be felt between the buttocks. By placing one 
finger in the rectum the dislocation of the coccyx could be still more easily felt ; 
forcible pressure downwards and towards the right buttock caused it suddenly 
to glide into its normal position, whereupon the patient declared herself re- 
lieved, as if roused from a dream, and all her pains vanished. She could move 
about freely ; but pain in the sacro-coccygeal region prevented her sitting up ; 
her expression was also completely changed. After a few days, a dull pain in 
the sacro-coccygeal region preventing sitting, was all the uneasiness that re- 
mained ; and in five days, all of this that was left was a slight burning sensation 
at the injured spot." The irritation of the spinal marrow observed in this case, 
in which only the very lowest filaments could have been disturbed, and which, 
nevertheless, sent the stream of disturbance to the brain itself, is a most inte- 
resting example of mechanical irritation, as evidenced by its instant disappear- 
ance on the reduction of the dislocation. — Ed. Med. Journ., Nov. 1858, from 
Betz. Memmorab. aus der Praxis, 1857, and Prag. Vitljschift, 1858. 

33. Impermeahle Stricture. — M. Charles Phillips terminates a series of pa- 
pers upon this subject with the following conclusions : 1. The transformation of 
tissues produced by urethritis may completely obliterate the canal. 2. Complete 
obliteration takes place more frequently after traumatic action than after simple 
inflammation. 3. It is always complicated with urinary fistulse. 4. Complete 
obliteration is perfectly distinct from stricture termed impermeable. 5. This 
latter always allows a certain portion of urine to pass, either at more or less close 
intervals, or continuously drop by drop. 6. Wherever urine can pass, a bougie 
may be always introduced, on condition of our proceeding slowly, patiently, and 
with full confidence in the power of the instrument. 7. Perforation is the basis 
of the treatment of complete obliteration. 8. If the obstacle is situated in the 
s,traight portion of the urethra, it should be attacked by a trocar, the finger being 
able to follow and guide this through the tissues. When the obstacle is situated 
in the curved portion, we should first introduce a grooved canula into the perineal 
fistula, which may serve as a guide to the trocar passed by the meatus. 9. If 
retention of the urine is produced by stricture, catheterism should never be per- 
formed by means of a metallic instrument. Filiform bougies should be employed, 
which should be introduced slowly, and after a few minutes withdrawn. Each 
time a little urine is discharged, with relief to the patient ; and when his suffering 
becomes abated, we may fix the bougie, and the whole of the urine will be dis- 
charged over it. 10. If the introduction of the bougie is for the time impossible, 
and the retention becomes insupportable, supra-pubic puncture of the bladder 
should be resorted to. 11. If retention is complicated with infiltration of urine, 
and the introduction of the bougie cannot at once be accomplished, the supra- 
pubic puncture should be made, as should be large incisions into the perineum. 
After a few days the tissues will have become sufficiently disgorged to admit of 
new attempts at catheterism. Not being now pressed by the patient's sufferings 
from retention, we may proceed slowly and cautiously, and we shall traverse the 
stricture erroneously believed to be impermeable. — Brit, and For. Med.-Chir. 
Rev., Oct., 1858, from Bulletin de Th^rap., torn. liv. 

34. Internal Urethrotomy. — Prof. Sedillot has been publishing, in the Ga- 
zette Hehdomadaire, a series of cases showing the efficacy of cutting stricture 
upon a filiform bougie. The sine qua non of the operation is, the passing of 
this bougie into the bladder, and it is upon it that the secator runs along and 
divides the stricture. The most desperate cases, not only of stricture, but of 
retention, were instantaneously cured in this manner, the patients not requiring 
afterwards the use of dilating instruments. Both straight and curved secators 
are used, as the stricture is anterior or posterior to the pubic arch. M. Sedillot 



1859.] 



Surgery. 



261 



deprecates the use of bougies after the operation, and now looks upon the ex- 
ternal incision, or perineal section, as it is called, as only exceptionally of use. 
The propositions which the author wishes to establish are the following : — 

1. Dilatation in simple cases. 

2. Internal urethrotomy when the stricture cannot be permanently dilated, and 
allows the introduction of a bougie ; whether the case be complicated or not 
with inflammatory or traumatic retention. 

3. Perineal section, when the permeability of the canal does not suffice for the 
disappearance and cure of the complications ; and when burrowing and infiltra- 
tions about the perinaeum require the incision of that region. 

4. Perineal section is again required in those happily very rare cases where 
the morbid changes in the canal offer an insurmountable obstacle to the intro- 
duction of a filiform bougie into the bladder. — Lancet, Nov. 27, 1858. 

35. Vesico-Vaginal Fistula. — Dr. Geo. Buchanan has published {Glasgow 
Med. Joiirn., Oct. 1858) an account of a case of this, successfully operated on. 
in the Glasgow Eoyal Infirmary, by our countryman. Dr. Bozeman. We omit 
the details of this case, but give Dr. Buchanan's remarks, as we are sure they 
will be read with interest. 

''I have published this case at Dr. Bozeman's request, and because the merits 
of this operation are still doubted in some quarters. True, it has not succeeded 
in every case, and in some instances death has been the issue ; but the same can 
be said of every operation in surgery, however simple. There can be no doubt, 
however, that a measure of success has followed this proceeding which cannot 
be affirmed of any other mode of treatment. I do not intend to add any statis- 
tical or critical account of its success, but it may be proper to allude to the plan 
of Dr. Sims, of New York, who claims a large amount of success for his opera- 
tion. To him belongs the credit of having introduced all the preliminary steps 
of the operation as performed by Dr. Bozeman. The use of the single broad- 
bladed speculum, and the position of the patient on her knees, does away with a 
great part of the difficulty of operating on a part so concealed and inaccessible 
as the wall of the vagina. The formation of a broad, bevelled raw edge round 
the fistula affi^rds an extensive surface for union. The introduction of the sutures 
at a distance from the edge of the wound, allows an amount of traction and sup- 
port which cannot be attained by stitches placed close to the incision. Above 
all, the employment of thin silver wire as a substitute for silk thread prevents 
the ulceration, or cutting out, which is inevitably caused by organic substances 
imbedded in the living tissues. It has recently been found, by various experi- 
menters, that it is of little consequence what metal is used, and iron, copper, and 
platinum wires have been found to act as well as silver ; and the material which 
may ultimately be chosen as the best suture, will depend on the flexibility of the 
metal. 

"Dr. Bozeman, in the accounts which he has published of his operation, freely 
acknowledges that, in the proceedings above mentioned, he has closely followed 
the directions of Dr. Sims, and only claims for his method of fixing the wires by 
a metallic shield, an amount of success which has not followed that of Dr. Sims, 
who employs two bars of lead, after the manner of the quill suture. This me- 
thod of drawing the edges of the wound together, called by Dr. Sims the ' clamp 
suture,' is a decided improvement on the common interrupted suture ; but the 
use of a metallic shield, as recommended by Dr. Bozeman, seems to make the 
operation perfect. By its use, the wires can be pulled perfectly tight, and the 
vaginal aspect of the incision is drawn up into the concavity of the shield ; so 
that towards the interior of the bladder is presented, not the liae of the wound, 
but smooth lips of mucous membrane. The shield also prevents the vaginal and 
uterine secretions from coming in contact with the wound, which is thus pro- 
tected, both externally and internally, from the presence of irritating fluids. In 
the case detailed, the menses flowed during the progress of the cure ; and, had it 
not been for the shield, there is little doubt that a considerable irritation would 
have been set up. 

"It is much to the credit of American surgery that this distressing afiection 
can now be treated, with a probability of success even greater than many other 



262 



Progress of the Medical Sciences. 



[Jan. 



sui'gical diseases; and the surgeons of this country cannot fail to recog-nize the 
claims both of Dr. Sims and his follower, Dr. Bozeman. Dr. Sims has done 
much by perfecting the operative part of the proceedings, but we cannot deny 
to Dr. Bozeman the merit of adding the last, a very essential part, of the treat- 
ment. It only remains to add, that the whole hospital stalF, as well as the other 
medical men who were present at the operation here detailed, besides being satis- 
fied with the perfect adaptation of the operation to effect the end proposed, were 
unanimous in according to the skill of the operator a large share of its successful 
result. There was but one opinion, that while he was entitled to share in the 
credit of devising the means, his mode of employing them exhibited the master- 
hand of an accomplished surgeon." 

Another case of vesico-vaginal fistula, with anteversion and incarceration of 
the cervix uteri in the bladder, operated on by Dr. Bozeman at the Royal Ma- 
ternity Hospital, Edinburgh, is recorded by Dr. Alex. Keiller [Edinburgh Med. 
Journ., Oct. 1858). This case terminated unfortunately, but Dr. K. bears tes- 
timony to the ingenuity displayed by the operator in effecting the objects of the 
operation, and to the skill with which it was performed. Indeed, ihe. post-mortem 
examination, he says, showed that the special mode of operation adopted in this 
case fulfilled the object intended, and he ascribes the unfortunate result, in great 
measure, to the unfavourable bodily and mental conditions of the patient. 

36. Rupture of an enormous Ovarian Cyst into the Peritoneal Cavity ; per- 
manent Cure. — The following remarkable example of this is recorded by C. Fae- 
RAR in the British Medical Journal, Oct. 23, 1858 : — 

"Mary B , aged 36, a tall, spare woman, apparently pretty healthy, about 

eleven years since, being at the time five months pregnant, fell over a trough on 
the left side, and from the injury was confined to her bed for some weeks. After 
her delivery it was found that the abdomen had scarcely diminished in size, and a 
large fluctuating tumour was detected in the left side. For several years the tu- 
mour steadily increased, until it completely distended the abdominal cavity, and 
acquired the magnitude which it had at the time of the occurrence of the accident. 

"About eighteen months since she stumbled and fell upon the abdomen on a 
brick floor. She became collapsed, and had violent rigors ; and in a few hours 
inflammatory fever set in, accompanied with acute abdominal pain. She lost flesh 
rapidly, was unable to lie down, and in a few days enormous anasarca of the legs 
and body up to the waist came on. The urine was nearly totally suppressed, and 
so severe were the symptoms that no hopes were entertained of her life. In about 
a fortnight she began to improve, and passed daily a large quantity of turbid urine. 
At the same time the anasarca rapidly disappeared. One month from the date of 
injury the tumour had nearly disappeared. 

" I examined her fourteen months after the fall. She expresses herself, with 
unbounded delight, as being perfectly well, and able to walk any distance, which 
she had not done for some years. On examining the abdomen, there are merely 
the hardened pedicle and sac of the former tumour to be felt, and these appear to 
be rapidly diminishing in size. Of course there is a large quantity of pendulous 
skin upon the abdomen, which time alone will reduce to its proper form and size. 

" Her general health has improved very much. She has gained flesh, and has 
lost the wan appearance that she previously presented." 



OPHTHALMOLOGY. 

37. Colohoma Iridis. — Mr. J. F. Streatfeild, the editor of the Ophthalmic 
Hospital Reports, states in a recent No. of his excellent journal (No. TV., for 
July, 1858), that so many cases of coloboma iridis have come under his observa- 
tion, that he believes it to be a very common congenital defect, and he relates 
the two following examples of it : — 



1859.] 



Ophthalmology. 



263 



"In the first instance, a boy was brought to the Royal London Ophthalmic 
Hospital, with simple conjunctivitis. For the same kind of ophthalmia he had 
been at the hospital before ; he had also a moderate sized cleft of both irides in 
the common downward direction. The parents seemed quite aware of the pecu- 
liarity, and said he was, like others of their children, very ' long-sighted.' 1 then 
went to their house, and found their statement true : his eldest brother had a 
similar defect in both eyes, and his youngest brother the same in one eye, and the 
symmetrical indication of the deformity in the other. The mother's father was 
said to have had the same defect in both eyes, and his brother also in both eyes, 
and her eldest brother was similarly affected, and his eldest son had the ' long- 
sight' (as it was called in their family) . This young man I afterwards saw, and 
found his irides just as they had described, but of the incomplete form. In the 
four of these seven cases, I examined (and in the others, as well as I could learn 
the facts) , the vision and power of accommodation of the defective eyes were 
good; the irides were gray, excepting in the case (at the end) last mentioned ; 
they were all healthy, and had no other defects. The cleft iris seems to have be- 
longed to the males of the mother's family. The mother herself had perfectly 
natural pupils, and four of her children (a boy and three girls) were also un- 
affected. The parents were positive that those of their children that had the 
' long-sight' had also a predisposition to ' colds in the eyes,' such as that for 
which the first-mentioned case had been to the hospital in the morning. 

"In the second instance, the patient I had an opportunity of examining was a 
gentleman who had the cleft in both irides extending in a direction down and in- 
wards through the irides to the greater circumference, and perfectly alike in the 
two eyes. His irides had the usual markings, were brown in colour, and active. 
Vision was in all respects good, and there was no other defect known or percepti- 
ble. His sister and two cousins, he knew, had the same peculiarity of their 
pupils, and in colour of irides and the other particulars I have mentioned of his 
case, their cases, as he affirmed, resembled his own. His grandfather, he believed, 
had the same defect. 

" The extent to which the cleft, or even the indication of coloboma may reach 
from the pupil towards the attachment of the iris (if it extends no further) is 
very variable. A young woman, who ' never had anything the matter with her 
eyes ;' and who had no adhesions of the iris in either eye, has been lately shown 
to me. The apertures of both pupils were conical; the right pointed down and 
outwards, and only extended from the axis, through about half the breadth of 
the iris ; the point of the left was directed up and inwards, and did not reach 
further from the centre than in the other eye ; but a little beyond the apex of the 
cleft, the coloboma, in the incomplete form, was extended in the radial line, ex- 
posing the dark uvea, nearly to the greater circumference of the iris. 

" Double coloboma of the same iris has been recorded, and so have cases of 
incomplete cleft iris, but the case of the young man, above referred to, is pecu- 
liar in having combined these two characteristics, and in having no cleft of either 
iris but the symmetrical indication of it in hath irides. The patient was, as I 
have related, one of a family of which several members had cleft irides ; his sight 
was perfect, and his eyes had never been inflamed ; his irides were rather defi- 
cient in the usual markings, of brown colour, and very active ; his true pupils 
(ophthalmoscope) were both circular. The right iris had the indication of colo- 
boma vertically downwards from the pupil, the dark fissure not extending through 
the uvea of the iris, and not further than midway between the pupillary edge and 
the greater circumference. The left iris had the double defect ; the separation 
exposing the uvea in this eye was wide at the margin of the pupil, and extended 
below nearly to the greater circumference of the iris, in two divisions, one of 
which corresponded to the furrowed iris of the right eye, and the other was to 
its outer side. This mark of the iris had somewhat the effect of a deep impres- 
sion of the letter W on its surface." 

38. Irideremia. — Mr. Dixox records the following case of this : — 
Caroline P., aged 36, applied at the Royal London Ophthalmic Hospital in 
August, 1857. She had evidently suffered from chronic inflammation of the cor- 



264 



Progress of the Medical Sciences. 



[Jan. 



nea, both were slightly hazy and traversed by a few tortuous veins. There was 
no general redness of the sclerotic, no intolerance of light, nor any signs of acute 
disease. Both upper lids drooped very slightly, giving the patient rather a 
sleepy and heavy appearance. She could not read ordinary type, but with the 
right eye, where the cornea was less hazy than in the left, she could make out 
large capitals. Opposite the centre of each cornea was a white speck, evidently 
situated in the lens, but neither the outline of the pupils nor the tissue of the 
irides could be distinguished. It seemed unlikely that such a degree of corneal 
haziness as permitted an opacity of the lens to be seen could, at the same time, 
prevent a view of the iris, and a more careful scrutiny convinced me that the 
irides were wholly absent. A moment's glance with the ophthalmoscope proved 
this to be the case, the whole area of the cornea presenting the reddish glow of 
an illuminated retina. Across this field a few corneal veins were seen ramifying, 
while, in the centre, the black, nuclear opacity of the lens, stood out in bold re- 
lief, surrounded by a few widely separated striae radiating from the circumference 
of the lens. When speaking of the irides as absent, I should observe that, be- 
hind the upper and inner margin of the left cornea a very narrow, scarcely trace- 
able, brownish line indicated a rudiment of iris. 

It seems singular, that with central and radiating opacities of the lenses, hazy 
cornea, and absence of irides, the patient still enjoyed a useful amount of sight, 
and her previous history is still more remarkable. She assured me that until the 
occurrence of the inflammatory attack a few years ago her sight had been excel- 
lent, and she was quite surprised at my having had any doubt on the subject. 
She went to school when ten years old, and took her place with other girls at the 
ordinary tasks and needlework, and so good was her progress, that at sixteen she 
went as housemaid into the household of a nobleman, remaining there and in an- 
other situation for eight or ten years. She stated that, as a girl she never suf- 
fered any inconvenience from bright sunlight or candlelight, and saw distant and 
near objects equally well. Both her parents, and several brothers and sisters, 
had good sight. 

The case is still (June, 1858) under treatment, and some improvement in the 
condition of the cornege has taken place. The movements of the eyeballs have 
always been perfectly natural, no trace existing of that unsteadiness which, as 
far as I have seen, characterizes irideremia in infants. — Ophthalmic Hospital 
Reports, July, 1858. 

39, Inutility of Depletion in Syphilitic Iritis. — Mr. J. Hamilton, Surgeon to 
the Eichmond Hospital, states [Dublin Hospital Gaz., May 15, 1857) his belief 
" that in the treatment of syphilitic iritis, even the most acute cases, all that is 
necessary to be done is to administer mercury properly, suited to the constitu- 
tion of the patient, and the nature of the case, and till full salivation ; and the 
application of the extract of belladonna round the eye, or of the solution of 
atropine in the eye. I totally disagree with those authors — Mr. Tyrrell, for in- 
stance — who recommend, in cases where the patient is broken down, to adminis- 
ter tonics, &c., till he is able to bear the mercurial course, the real fact being, 
that the best tonic is the mercury, combined with opium, which by expelling a 
depressing poison from the system, invigorates it, at the same time that it arrests 
the ravages of a destructive specific disease ; whereas, while waiting for the 
effects of tonics and diet, the eye may be lost. There could not be, apparently, 
more feeble or depressed subjects than No. 3, Mary Byrne, or No. 4, John Cal- 
laghan, particularly the latter, who was literally nothing but skin and bone, with 
a pale sallow face, contrasting with the large red tubercles with which it was 
studded, and so weak he could scarcely stand ; yet, under the beneficial action 
of the mercury, while the eye was saved, his fiesK, strength, and complexion, all 
became rapidly restored, so that in his last letter to me, he describes himself, in 
language more remarkable for strength than orthography, ' as strong as a hoss, 
and as fat as a wheal !' 

" Many surgeons do not deplete, but the large majority still do, by leeches and 
cupping ; rarely, I believe, in this country, by venesection, as recommended by- 
Mr. Mackenzie. During fourteen years, a very large number of cases of syphili- 



1859.] 



Ophthalmology. 



265 



tic iritis have been under my care in the Kichmond Hospital, and I have only 
cupped in one case ; and with my present experience, I am sure if that case pre- 
sented itself now, I should not do so." 

As this is one of those practical questions best decided by facts, Mr, Hamil- 
ton quotes five cases from his case-book in support of his views. One of these 
cases we quote : — 

" John Oallaghan, aet. 24, transmitted into No. 4 ward of the Eichmond, from 
the Whitworth Hospital, February 26th, 1857. He is one of the city police, and 
was once a stout powerful man, but is now sickly-looking, sallow, and emaciated. 
A thickly scattered eruption of tubercles over the face, on the eyebrows, sides 
of the nose and chin. He became infected with syphilis about ten months ago, 
and has since suffered from pains in his bones, sore throat, and eruptions, with 
rapid decline of health and strength. He has taken mercury irregularly. Ten 
days ago the right eye became tender and inflamed, and quickly got very bad. 
His only treatment had been one leech and a blister to the temple, and bark 
mixture ; but he had taken no mercury for a month. 

" The right eye is affected with acute iritis ; the sclerotic of a deep dull red, 
most marked round the cornea; the conjunctiva also is traversed by many large 
red vessels ; the iris of a dull yellowish-gray, contrasting with the clear bluish- 
gray of the other eye ; the pupil hazy and irregular, adhesion existing at the 
lower and outer rim, where the iris is of a dull reddish-brown, as if a tubercle 
was about to form there ; the pupil is nearly as large as the other, perhaps slightly 
affected by the extract of belladonna which was applied last night ; sight very 
much injured — though he can see me in a bright line at three feet, he cannot dis- 
cern a feature of my face; intolerance of light, and some lachrymation ; pain in 
the brow, extending to the eyeball and temple, begins at ten o'clock at night, and 
lasts till one o'clock A. M. Submur. hydrarg. 9j, opii gr. ij, in pilulas x. 

" Third day. Eye somewhat clearer ; the deposition of rusty-coloured lymph ap- 
pears less ; not so much pain last night. He has taken eight pills, but no per- 
ceptible effect on the mouth, nor any griping. The belladonna has had no influ- 
ence on the pupil. 

" Fifth day. The mouth is sore, and there is some griping. The eye is better, 
and he can distinguish my features, and the studs on my shirt. To take a pill 
night and morning. 

" Seventh day. Mouth fully sore ; a very decided improvement in his vision, 
and the appearance of the eye ; the iris clearing, and the rusty lymph absorbing ; 
pupil clear and black, and the redness much less. He bears light better ; no 
nocturnal pain of the brow the last two nights ; the eruption of tubercles on his 
face and body are fast disappearing. 

" On the twelfth day the eye was not so well, more vascular and uneasy — evi- 
dently an attempt at a relapse. By increasing the quantity of mercury for two 
days, he got better ; all traces of the iritis afterwards entirely disappeared. 

" On the twenty-second day, having been quite well for several days, he re- 
quested his dismissal, wishing to go to the country. I had a letter from him a 
few days since, saying that he had regained strength and flesh, that the sight of 
the eye was as good as ever, and no traces of the eruption existed. He had 
continued to take the mercury so as to keep up the mercurial action in the sys- 
tem, altogether for about ten weeks." 

40. Hemeralopia treated by Azotized Vapour. — M. Deval relates (L' Union 
MSdicale, No. 78, 1858) a case of hemeralopia, occurring in a lad ten years and 
a half old, and dating about ten days. No cause whatever could be assigned for 
its production. Quinine, valerian, and opium, were resorted to on account of the 
periodical character of the affection, in the absence of any definite indication ; 
but as these proved of no avail, M. Deval determined to try the effect of a remedy 
much praised of late. This consists in exposing the eyes to the vapour arising 
from a decoction of ox-liver, the application taking place for ten or fifteen mi- 
nutes morning and evening. Great was his surprise to find the hemeralopia 
entirely gone after the second of these applications, although they were continued 
a while longer as a matter of precaution. The employment of the remedy dates 



266 



Progress of the Medical Sciences. 



[Jan. 



as far back as 1762, when Dupont described it as used in the garrison at Stras- 
burg. The vapours arising from the livers of sheep or calves have since been 
employed with advantage by Stoeber and others, and quite recently by several 
Italian practitioners. — B. and F. Med.-Cliirurg . Rev., Oct., 1858. 



MIDWIFERY. 

41. Duration of Pregnancy. — Elsasser records his observations on the dura- 
tion of pregnancy, made in the Stuttgard Institution. He is of opinion that no 
single method of computing the length of pregnancy can be taken as trust- 
worthy ; neither the date of conception, nor menstruation, nor the first foetal 
movements. By the reckoning from the day of conception, out of 260 mature 
children, only 23, or 8.8 per cent., were born on the 280th day; 166, or 63.8 per 
cent., before, and 71, or 27.3 per cent., after this day. The greatest number of 
births (126 = 48.4 per cent.) fell between the 271st and 280th days. Of the 
recorded cases, 140 were first births ; of these, gestation lasted in 14 exactly 
280 days ; in 96 a shorter time, and in 39 longer. In 111 pluriparse, 9 lasted 280 
days, 70 less, and 32 longer. The sex of the child appeared to exercise no in- 
fluence. In reckoning from the commencement of the last menstruation, out of 
175 deliveries, 12 = 6.8 per cent, took place on the 280th day ; 43 = 24.5 per 
cent., before ; and 120 = 68.5 per cent., after. The greatest number of deliveries 
fell between the 280th and 290th days. Thus, by the reckoning from the begin- 
ning of the last menstruation, 93 per cent., and by the reckoning from concep- 
tion, 91.1 per cent, of all the cases lasted a less or longer time than 280 days. 
The weight of the children is in no constant relation with the length of the gesta- 
tion. — Brit, and F. Med.-Chirurg. Rev., Oct., 1858, from HenTce's Zeitsclirift, 1857. 

42. Port Wine Enemata as a. Substitute for Transfusion of Blood in cases of 
Post-Partum Hemorrhage. — Dr. H. L. Williams recommends enemata of port 
wine in cases of post-partum hemorrhage, and records [British Med. Journ., 
Sept. 4, 1858) a case in which he successfully resorted to it. The patient was 
in the most alarming state of prostration, pulseless at the wrist, with cold ex- 
tremities, &c. Dr. W. commenced by administering four ounces of port wine 
with twenty drops of tincture of opium. The patient speedily manifested signs 
of improvement. In half an hour he repeated the enema, with marked advan- 
tage, and the patient was soon out of danger. 

43. Inversion of the Uterus successfully reduced. — Dr. F. S. Yerity, of Hem- 
mingford, records [Medical Glironicle, Montreal, Nov., 1858) the following inte- 
resting example of this : — 

Mrs. R. was about 40 years of age, and the mother of 9 children; her figure 
was squat and round, showing a large roomy pelvis ; the abdomen pendulous ; 
her health strong and rugged. She was taken in labour with her 10th child, 
and, while walking up and down, a sudden pain expelled the child, which fell on 
the floor, and was not materially hurt. Not so, however, the mother : the same 
pain which forced the foetus from the uterus, "brought down," to use the words 
of the messenger who came for me, " the whole of her inside." I arrived at the 
scene of the accident about an hour afterwards. I found the woman lying on 
her back on a mattress placed on the floor, deluged in blood. She was moaning 
and sighing, tossing her arms wildly about, and gasping for cold air. Her pulse 
could scarcely be felt at the wrist, and her countenance was blanched and 
ghastly. When the nurse turned down the bedclothes I was stunned ; I saw 
before me my first, and I devoutly hope my last, case of " inversion of the uterus." 
Occupying the space between her thighs and nearly reaching down to her knees, 
was a large red membranous-looking mass, from which blood was oozing, and at 
its lowest part (the fundus), almost disguised by clotted blood, was attached the 
placenta. I immediately administered a tumbler of spirit and water, cold, with 



1859.] 



Midwifery. 



26t 



tr. opii in it ; applied warmtli and friction to the extremities, and, without wait- 
ing, forthwith proceeded to reduce the uterine mass to its proper position. After 
cleansing it from the clotted blood, the question arose in my mind, shall I reduce 
without removing placenta or not ? Fearful of increasing the hemorrhage, I 
determined to reduce with the placenta attached. Recollecting the rules laid 
down in the books, I began the attempt, and an attempt it was only. As soon 
as I touched the uterus, it contracted and shrunk, and gave me the feeling as if 
I was holding a live eel in my hand. I tried two or three times gently, but firmly, 
to reduce it according to the usual directions ; but I made not the least impres- 
sion on it. The weight of the placenta bothered me greatly ; for on attempting 
to return the part that had last protruded, it was constantly dragged out of my 
fingers by the weighty placenta. The rules were now useless to me. What was 
to be done, hemorrhage still going on and the woman sinking ? I determined to 
remove the placenta, and reduce the uterus by pressure on the fundus. I quickly 
detached the placenta, and was most agreealjly surprised to find there was very 
little hemorrhage ; in fact after it was removed the mass shrunk in volume.* I 
now placed my left hand and forearm under the organ, and supporting it in a 
line with the proper axis, with my right hand half shut, I pressed the tips of my 
rounded fingers firmly against the fundus, and pushed it upwards until my fingers 
were arrested by the constricted os. I made firm, but cautious, pressure against 
it, and in about half a minute I felt it yield, I then boldly, but cautiously, car- 
ried my hand upward in the axis of the pelvis, and, when my wrist was passing 
the constricted os, the fundus suddenly shot from my hand, and the organ re- 
sumed its usual position. Retaining my hand within the uterus for a short time, 
constriction took place, and the uterus returned to its proper state and condi- 
tion. Of course I waited and watched. I gave her an opiate, and, at the end of 
6 hours, left my patient safe for the present. The loss of blood had been fright- 
ful : I ordered broths and nourishment, and on leaving gave the strictest injunc- 
tions to maintain the horizontal position. The next day she was very much im- 
proved, and in good spirits. I introduced the catheter twice in the 24 hours ; 
kept her perfectly still ; nourished her well with broths, &c., and forbade her on 
any account to rise in bed. On the third day, I was suddenly sent for, when I 
had the inexpressible mortification to find she had just died. It appears that 
her nurse did not think her clothes clean enough, so a change of night-dress was 
resolved on. She sat up in bed to make the requisite change. After complain- 
ing " of giddiness and singing in the head," she fell back on her pillow and 
expired. 

44. On some of the Morbid Conditions which give rise to Sterility in Women. 
— Dr. Carl Mayer read a paper on this subject before the Obstetrical Society 
of Berlin. He showed that notwithstanding the important investigations of mo- 
dern times upon the subject of conception, we have not yet made much progress 
in reference to it, inasmuch as we are still ignorant of the conditions under which 
this interesting occurrence is brought about, and of its further course. Although, 
too, the brilliant results recently afforded by the microscope deserve the greatest 
attention, and have both already borne, and shall certainly still bear, important 
fruits, a great number of practical questions have as yet received no elucidation. 
We still know as little as we formerly did, why conception results from a parti- 
cular connection, while in a hundred or a thousand instances it does not follow from 
intercourse under the same external conditions. We are as yet unable to explain 
why many healthy women conceive only at regular intervals of three, four, five, 
or more years, notwithstanding the connection regularly takes place during the 
intervals. We cannot say why women often conceive for the first time after 
several years of married life (the speaker saw it once occur after the lapse of 
twenty-five years) ; we cannot give a reason why one marriage should prove un- 
fruitful, while the same individuals entering into another should beget and bring 
forth children. But such questions are very important in a practical point of 
view, for in the existing state of ignorance of the conditions necessary to con- 
ception, we grope in the dark in the investigation of the causes and in the treat- 
ment of sterility. Hence, too, it comes, that physicians, in cases in which they 
give advice to barren women as to the attainment of their most ardent wish, in 



268 Progress of the Medical Sciences. [Jan. 

general catcli quite empirically at this or that remedy famed of old, and preserve 
only the appearance of a rational treatment when among the bath cures recom- 
mended in sterility, they prefer, bearing in mind the general constitution or ex- 
isting morbid condition of the patient, a strengthening chalybeate or sea-bath for 
the weakly, frail, or nervous — a resolvent or ioduretted spring for the strong, 
plethoric, overfed, or too fat patient, suffering from abdominal derangements ; and 
a more stimulating bath for the unexcitable, passive, insensitive woman. When 
in such cases the several springs have the desired effect, it will be doubtful 
whether the fortunate result is due to the bath or to some other circumstance. 
Often has the abstinence from intercourse occasioned by the journey the best 
effect. As to the capacity for conception of insensitive, unexcitable women, it 
is certain that sensual excitation is not necessary' to conception, that even women 
conceive who have a decided aversion to intercourse, while, on the contrary, very 
sensitive women frequently have no children. 

But there is also a series of pathological conditions in the female organs, which 
are more or less easily recognizable and curable, and it is the bounden duty of 
the physician to direct his most earnest and fullest attention to these states, and 
by a careful investigation to ascertain the cause of sterility in any given case 
which may come before him. One would think that such an investigation should 
be a matter of course, and that no physician would omit it ; but unfortunately 
experience shows that in numberless instances unfruitful women have been for 
years treated by various medical men, and sent to the most different baths, until 
at last an examination has proved that conception was quite impossible on ac- 
count of the existence of local obstacles. Among the patients treated by the 
author there was, for example, the wife of an official, a person of weakly consti- 
tution, who had for several consecutive years been sent by her physicians to the 
sea, on account of sterility. To the question, whether an examination had been 
made, a negative was returned. On investigation it was ascertained that the 
vagina, which was scarcely one inch and a half in length, presented no trace of 
an OS uteri, the short cul-de-sac was formed by a very dense hymen, which by 
reason of its great dilatability had permitted an imperfect connection to take 
place. At the upper edge of the hymen was a small opening of the circumference 
of a quill, through which the menses had found an exit. The introduction of a 
probe through the opening, demonstrated the existence of a vagina, examination 
through the rectum proved the presence of the uterus. A slight operation with 
the knife destroyed the membrane, and in four weeks afterwards conception en- 
sued, and the lady is now the mother of several children. This case is by no 
means singular ; on the contrary, the author can state that in the greater num- 
ber of women seeking his advice under the circumstances, no examination had 
been made ; he therefore considers it not superfluous, but urgently necessary, to 
remind his brethren that they neglect their duty when they omit an examination 
in cases of sterility, that they act inexcusably, and are unworthy of the confidence 
reposed in them, when without this preliminary step they lay down any plan of 
treatment whatever. 

The author divides the several malformations, abnormities of development, and 
pathological changes affecting the female genitals, into two groups, according to 
their situation. 1. Those which occupy the external genitals, the orifice of the 
vagina, the vagina, the external and internal os uteri, and either wholly or in 
part prevent intercourse, rendering impossible the necessary penetration of the 
semen into the cavity of the uterus, and its contact with a mature ovum capable 
of fructification. 2. Those implicating the ovaries, the tubes, and the cavity of 
the uterus, and preventing either the development or separation of a mature 
ovum, or its further normal progress, or its organic connection with and attach- 
ment to the soil appointed by nature for its growth. The conditions belonging 
to the first group are recognizable by an exact examination, and are frequently 
capable of being even easily removed ; those of the second are during the lifetime 
of the patient not at all accessible to the eye, and only with difficulty to the 
sense of touch, and render the diagnosis uncertain, and the cure very difficult. 

' This is fully illustrated in Dr. Montgomery's important and valuable work on 
the "Signs and Symptoms of Pregnancy." Second edition, pp. 361-365. 



1859.] 



Midwifery. 



269 



The author does not go through all the anomalies belonging to this class, but 
quotes only the more important, adding some short observations from his own 
experience. 

Among the diseases of the second group the ovaries play the most important 
part, as they undergo the most manifold changes, and are then of course not in 
a state to form healthy ova, and so cause sterility. If an increase of circum- 
ference does not at the same time take place, this condition is neither to be re- 
cognized nor removed. It is only the frequently occurring and often overlooked 
chronic inflammation of the ovaries, which is recognizable and curable, and is 
consequently of greatest importance in connection with the present subject. The 
chronic inflammation often lasts for years, causes the most violent dysmenorrhcea 
and sterility, is seldom combined with violent local pains, except at the time of 
menstruation, but it is almost always attended with consensual and hysterical 
nervous affections. On simultaneous internal and external examination, we find 
the ovaries swollen and painful, and in general soft. In such cases the ordinary 
anti-spasmodic and narcotic remedies are of no avail; it is only local antiphlo- 
gosis, with a mild derivative treatment, which is of use. The employment of 
leeches must sometimes be frequently repeated, and in a case more fully quoted 
by the author it had to be resorted to nine times before a permanent cure was 
effected. The opinion often put forward by physicians, as well as by non-pro- 
fessional people, that the pains of menstruation cease after marriage, does not at 
all hold good in chronic inflammation of the ovaries, on the contrary, the inflam- 
mation is increased in consequence of intercourse. 

Another pathological condition of the second group is formed by closing of 
the tubes, with or without adhesion or attachment of the fi-mbrise to the neigh- 
bouring organs. But we have not as yet succeeded in recognizing this change 
in the living subject, and the tube-sound recommended by Tyler Smith neither 
attains its object, nor is free from danger. 

The several morbid conditions of the inner wall of the uterus are also neither 
to be seen nor felt in the living subject; but from their results we can with tole- 
rable accuracy draw inferences as to their existence, and under certain conditions 
employ instruments and remedies for their relief. Thus chronic endometritis 
gives rise to a profuse, gelatinous, transparent secretion, which with the aid of 
the speculum we can see issuing forth from the os uteri, and which is particularly 
characteristic, and very important in reference to sterility, inasmuch as it hinders 
the access of the spermatozoa to the internal genital organs, and does not pro- 
vide a suitable soil in which the ovum, arrived in the uterus through the tube, 
may take root; the ovum must perish, even though it come in contact with the 
most healthy spermatozoa. The formation of this peculiar secretion constitutes 
one of the most obstinate varieties of uterine affection, and the author never saw 
a woman labouring under it become pregnant, while the flow of mucus which so 
very frequently occurs in consequence of various morbid conditions of the mucous 
membrane of the lips of the os uteri, by no means causes sterility, and even can- 
cer of the uterus admits of conception taking place. The injections into the 
cavity of the uterus recommended in this affection are dangerous to life, and have 
given rise to fatal peritonitis. The author himself saw a very small quantity of 
a weak solution of nitrate of silver, though very carefully injected, and which 
certainly could not have reached the tubes, instantaneously produce the most 
violent nervous symptoms ; uterine colic with swooning, icy coldness of the ex- 
tremities, etc., which did not give way until after the lapse of some hours, and 
quite resembled the effects produced in another case by a leech having made its 
way through the os uteri. Chronic endometritis produces various anomalies of 
menstruation, neuralgias of all kinds, especially in the stomach ; menstruation 
itself is at one time scanty, at another profuse, and is always combined with boring, 
tearing, or dragging pains in the womb, the sacrum, the hips, and thighs. A 
diminution of the transparent mucus attends menstruation. The entire womb is 
painful on examination ; in the speculum the soft, turgescent vaginal portion 
appears very red, hypersemic ; the lips of the os uteri are ulcerated around the 
opening, are of a scarlet red colour, and secrete a white, cream-like mucus. The 
author has not seen the oft-boasted advantage attend dilatation of the os uteri, 
No. LXXIIL— Jan. 1859. 18 



210 



Progress op the Medical Sciences. 



[Jan. 



or the division of its edges with tlie knife ; as little benefit has he observed from 
the use of caustic or astringent applications, or from the employment of cold ; on 
the contrary, he has seen a cure effected by a very long-continued derivative 
treatment, small local abstractions of blood, the application of blisters, followed 
by preparations of iodine, lukewarm injections, and suitable baths, and lastly 
iron, which is best given in the form of chalybeate miueral water. 

In the first group of changes of the female organs, more or less obstructing 
intercourse, are the degenerations of the external genitals, which admit of imme- 
diate recognition, as enormous hypertrophies, elephantiasis, tumours, and excres- 
cences, and atresias. Less apparent, but still always sufficiently recognizable, 
on examination, are inflammations of the parts surrounding the aperture, some- 
times attended with so high a degree of sensitiveness and pain, that the slightest 
touch cannot be borne, and intercourse is consequently impossible. Such con- 
ditions are often, through false modesty, long concealed from the physician ; and 
the author has seen many women in whom, after several years of married life, 
during which they have been always under medical treatment for constant hys- 
terical affections, he has found an uninjured hymen, and such excessive tender- 
ness of the genitals, that the examination, consented to with much reluctance, 
has been attended with convulsions and fainting fits. This great sensitiveness 
often exists from childhood in consequence of eruptions, ascarides, or onanism, 
or it is the result of frequently repeated violent efforts of powerful men to accom- 
plish intercourse in cases in which an insuperable disproportion exists between 
the organs. Local abstractions of blood, tepid fomentations, baths, etc., and 
dilatation with sponge, are the remedies on which we should in such cases rely 
for the removal of sterility. 

Not unfrequently the impossibility of accomplishing intercourse, arising from 
excessive painfulness, is caused by a peculiar affection of the urethra, a relaxed, 
turgid, and prolapsed condition of the mucous membrane, which Morgagni called 
fungous excrescences, also occurring from childhood. The projections have a 
dark red, spongy appearance, and protrude from the orifice of the urethra, vary- 
ing from the size of a lentil to that of a cherry, ; they are usually attended with 
a secretion of bloody mucus, and frequently give rise to but slight annoyance ; 
but, particularly when the affection of the mucous membrane extends deeply into 
the urethra, cause such violent pain to the touch, and consequently during inter- 
course, as to render the latter intolerable. It is a very obstinate affection, against 
which the most certain remedy is the knife or the actual cautery; caustics are 
usually ineffective. 

Similar sufferings are produced by inflammation of Bartholini's glands and their 
excretory ducts, and by its results, an affection which has been so well described 
by Huguier. These conditions are obstinate, not difficult to recognize, and yield 
best to an antiphlogistic mode of treatment. In the advanced stage incisions are 
necessary. Pencilling with tincture of iodine has also proved useful in several 
cases. 

Prolapse and procidentia of the uterus would hinder intercourse only in the 
rare cases in which the parts are not capable of replacement even in the horizontal 
posture. But if hypertrophy or prolongation of the vaginal portion be present, 
a condition easily mistaken for prolapse, reposition cannot avail, the vaginal por- 
tion would be only compressed and crookened by the attempt, and the semen 
could then not reach the cavity of the uterus. In such cases amputation alone 
remains, an operation much recommended by the author, and lately performed 
by him in a case which he has detailed. In this instance a soft, fleshy mass, of 
the thickness of a plum, about three inches long, round, very red, and painful on 
pressure, protruded from the genitals, having at its lower free extremity the 
soundest os uteri, giving exit to a clear, transparent mucus ; this mass was easily 
recognized as the hypertrophied vaginal portion, and was returned with difficulty. 
The sound passed five and a half inches, that is, three inches too far, into the 
uterus. Amputation with the knife gave rise to enormous hemorrhage, which 
was arrested only by the actual cautery ; the wound healed slowly, but perfectly, 
and at the end of six months the uterus resembled that of a woman who had borne 
children. 

The closing of the external and internal ora uteri is important in reference to 



1859.] 



Midwifery. 



211 



impregnation. This may occur in three modes: 1, by growing together or ad- 
hesion, by atresia; 2, by altered abnormal position of the external os in the 
altered directions or obliquities of the uterus, which are called versions ; 3, by 
compression of the os internum, in flexions. 

Actual complete atresia, at an age when conception is possible, is of the most 
extreme rarity, while in old women it is frequently met with. On the contrary, 
we more frequently find the external or internal os uteri exceedingly narrow and 
small, so that the finest probe can scarcely be introduced. The menstrual flow 
is then attended with various sufferings, and it is very advisable to enlarge the 
OS uteri, by slitting up its edges with a knife. If little polypous or fibrous ex- 
crescences close the os, they must be removed by operation. 

In the various versions of the uterus, especially anteversion and retroversion, 
the OS uteri is more or less pressed upon the neighbouring parts, and consequently 
closed against the seminal fluid. These versions occur tolerably frequently in 
women who have borne children, and are attended with many troublesome symp- 
toms ; they are more rarely met with in women who have not had children. Im- 
pregnation can take place only when we are able to give the uterus permanently 
its normal position, and to relieve the pathological conditions and complications 
on which its abnormal direction depended. 

The third and last form of closing the orifice of the uterus is found in the flex- 
ions of the organ, which are to be carefully distinguished from the versions. 
Flexion takes place always in the situation of the os internum, and attains to va- 
rious degrees ; conception cannot take place where flexion exists. Accordiag to 
the cases of flexions collected by Eockwitz from the journals of the author ( Ver- 
liandlungen der Gesellschaft fur Geburtsliulfe, 1852), there were among 117 pa- 
tients 26 barren, according to Yalleix 19 in 126. From more recent observations 
the author found, that of 272 barren women 97 suffered from flexions, and more 
particularly 60 from anteflexions, and 36 from retroflexions. Of these 97 cases 
only 29 were complicated with chronic endometritis, chronic oophoritis, hyper- 
trophy of the uterus, ovarian tumours, or with polypi, to which the sterility could 
be at the same time attributed. In 68 cases, therefore, flexion remains the pro- 
bable cause of sterility, recognizable by examination, and it is to be observed 
that none of these women had ever conceived ; the great number of those, there- 
fore, who after a miscarriage or delivery at the full term were attacked with 
flexion and did not again conceive, is not taken into calculation. After such 
statistics it cannot be doubted that flexion constitutes an obstacle to conception. 
But it is the duty of the physician to remove this obstacle, and at the same time 
the various sufiferings, which, especially during menstruation, are the results of 
flexion. A correct and certain diagnosis of flexions is attainable only by means 
of the skilful use of the uterine sound, in addition to the other methods of inves- 
tigation ; and the employment of this instrument should, therefore, not be omitted 
in such cases. The inspection of the os uteri through the speculum is also use- 
ful, inasmuch as the opening, which is usually rather gaping, is in anteflexions 
directed downwards, and in retroflexions upwards ; and, in the latter, the posterior 
lip is more frequently hypertrophied, presenting a darkened vascular appear- 
ance. The curability of flexions is certain, and, therefore, treatment is necessary. 
An experienced and cautious physician will soon recognize the cases in which, 
either on account of great hypertrophy of the uterus, of tumours, of intergrowth 
between the coverings of the uterus and the neighbouring organs, a cure is im- 
possible. In all other instances a persevering mode of treatment must be adopted, 
and even should no result be obtained in six or eight weeks, the attempt must be 
renewed. The author has himself cured a great many cases, and has not only 
removed severe affections of several years' standing ; but in eight cases has had 
the pleasure (once after twelve years' unfruitful married life) of seeing his patients 
conceive and bear living children. 

In conclusion, the author classifies the anatomico-pathological condition of the 
272 barren women examined by him. He found in 2, no uterus ; in 97, flexions, 
namely, 60 anteflexions, and 37 retroflexions ; in 38, versions, namely, 35 ante- 
versions, and 3 retroversions ; in 42, inflammatory irritation of the external geni- 
tals and of the orifice of the vagina, and among these in 14 women the hymen 
was found uninjured after several years of married life ; in 51 chronic endometri- 



212 



Progress of the Medical Sciences. 



[Jan. 



tis ; in 25, chronic oophoritis ; in 23, ovarian tumours ; in 12, uterine polypi; in 6, 
fibroid tumours on tlie uterus; in 9, hypertrophy of this organ; in 1, elephanti- 
asis of the external genitals ; in 6, no morbid condition was to be discovered ; 16 
anteflexions were complicated ; 1 with irritation of the pudenda, 4 with chronic 
endometritis, 5 with chronic oophoritis, 3 with tumour of the ovary, 1 with poly- 
pus of the uterus, 2 with hypertrophy of the uterus ; 13 retroflexions were com- 
plicated: 1 with irritation of the pudenda, 6 with chronic endometritis, 2 with 
chronic oophoritis, 2 with tumour of the ovary, 1 with fibroid tumour of the ute- 
rus, 1 with elephantiasis of the pudenda; 10 anteversions were combined; 2 with 
irritation of the pudenda, 3 with chronic endometritis, 2 with tumour of the ovary, 
1 with polypus of the uterus, 2 with hypertrophy of the uterus ; 1 retroversion 
was combined with chronic oophoritis. — Med. Times and Gaz., Oct. 16, from 
Monatschrift fur Gehurtskunde und Frauerkranklieiten, Nov., 1856. 



MEDICAL JUKISPEUDENCE AND TOXICOLOGY. 

45. On the Ligature of the (Esophagus in Animals in Toxicological Experi- 
ments. — A discussion has lately taken place among the members of the French 
Academy of Medicine, on the ligature of the oesophagus in dogs, as a means of 
preventing vomiting after the ingestion of chemical substances, and as a measure 
consequently indispensable to the study of the physiological action of these sub- 
stances upon animals. 

It is a well known fact, that the principal conquests of toxicology have been 
achieved by this kind of experimentation, and that the greater part of Orfila's 
experiments were made under the protection of the previous operation in ques- 
tion. But how did the illustrious professor, whose labours have for so many 
years exercised universal influence over forensic medicine, perform the ligature 
of the oesophagus ? It is a secret which would appear to be totally lost, so dif- 
ferent would the results he arrived at seem to be from those spoken of by our 
present experimentalists. 

Unhappily, Orfila has not, in his works, sufficiently explained his modus ope- 
randi, and he has barely escaped paying the penalty of the omission with his 
glory. What is known is, that the eminent professor made a puncture in the 
oesophagus, for the purpose of introducing into the stomach the substance, the 
action of which he desired to study, and that he then tied this duct below the 
artificial aperture, with a tolerably large and moderately tight ligature. We 
likewise read the following, on the effects of this operation, in his Treatise on 
Toxicology, p. 46 : — 

It is proved by fifty experiments, several of which have been publicly made 
before a numerous audience, and in presence of several members of the Academy 
of Medicine, that if the oesophagus, after having been isolated, is tied, and if the 
ligature is preserved for twenty-four or thirty-six hours, the animals thus ope- 
rated on merely feel slight depression and a moderate amount of feverishness. 
As soon as the ligature is removed, the dogs drink, soon begin to eat, and are 
perfectly restored to health." 

Whether, however, dogs die, or not, from the wound made in the oesophagus, 
after the first eight^and-forty hours, is unimportant ; the end was attained, and 
there was no reason for investigating the effects of a permanent ligature, which 
is useless in toxicology. What Orfila sought by a ligature of the oesophagus he 
obtained — the possession of a preservative means by which chemical substances 
might be retained in the stomach without itself occasioning symptoms which 
might be confounded with those resulting from the introduction of these sub- 
stances, or capable of causing poisonous properties to be ascribed to a harmless 
substance. 

Now, after an affirmation so positive as the one we have just quoted, and 
which the learned world had generally accepted as gospel truth, the surprise of 
the Academy will be readily imagined when, two years since, two Professors of 



1859.] 



Medical Jurisprudence and Toxicology. 



273 



the Veterinary School of Alfort, Messrs. Bouley and Reynal, came forward with 
assertions diametrically opposed to Orfila's. Messrs. Bouley and Eeynal sought 
to prove that the deligation of the oesophagus, far from being perfectly harmless, 
is generally attended with serious consequences ; that it is almost invariably 
mortal, when the ligature remains permanently applied, since it is capable of 
causing death in a short time, by the sole agency of the disturbances it occasions 
in the system, and so much the more rapidly that the substances ingested more 
powerfully excite vomiting ; that, in short, it is almost always followed, a short 
time after its application, by grave symptoms, which must be taken into con- 
sideration in the appreciation of the phenomena observed when the eSects of 
substances ingested into the stomach are investigated. 

The importance of a communication which shook all Orfila's toxicological edi- 
fice did not admit of indifference, and the Academy appointed a committee to 
resume and control the experiments of the Professors of Alfort, and the report 
of this committee was read by Dr. Trousseau on the 29th July last. 

In this remarkable production, Dr. Trousseau successfully examined the two 
principal questions of fact and of interpretation. It was first necessary to ascer- 
tain whether the ligature of the oesophagus is simple and harmless, as Orfila de- 
clared it to be, or whether it is attended with serious disturbance, as Messrs. 
Bouley and Eeynal assert. Further experiments were made at the Hospital of 
Yal-de-Grace. Messrs. Bouley and Eeynal performed anew the ligature of the 
oesophagus on five dogs, carefully avoiding to comprise the nervous filaments in 
the loops. Notwithstanding this precaution, extreme agitation, retchings, and 
nervous disturbance, were observed in the animals, and these symptoms singu- 
larly contrasted with the mere depression spoken of by Orfila. The temporary 
ligature, however, killed but one dog out of thirty-one. The permanent ligature, 
as was to be expected, was fatal to twenty-two dogs out of twenty-three. The 
greater part of these animals died from the third to the sixth day. 

The most important question of the debate was to ascertain whether the fatal 
results of ligature of the oesophagus, after the ingestion into the stomach of sub- 
stances subjected to experimentation, might not be the consequence of the com- 
bined action of the ligature of the oesophagus and the necessarily powerless 
efforts to reject these substances, even when not possessed of poisonous proper- 
ties. This fact seemed confirmed by the death of a certain number of dogs that 
had taken, before the operation, from one to three drachms of sea-salt, of sul- 
phate of zinc, of nitrate of bismuth, and even of lukewarm water. We will say 
nothing on the question of interpretation , it remained full of obscurity, and it is 
not precisely known why and how the victims of these experiments died under 
circumstances in which, according to Orfila's affirmations, they should have ex- 
perienced scarcely more than discomfort, or some insignificant disturbance. 

How deceptive or dangerous soever the results of experiments made on ani- 
mals, in less practised hands than those of Orfila, may now be, we cannot admit 
that a man gifted in so high a degree with the talent of observation could have 
deluded himself for forty years, and have confounded the phenomena peculiar to 
the action of poisonous substances with those which owe their origin to the liga- 
ture of the oesophagus. 

Dr. Cloquet, who witnessed several hundred experiments performed by the 
late Dean of the Faculty of Medicine (Orfila) , proved, in a few words in the dis- 
cussion, that the ligature of the oesophagus, performed with a thick and rather 
loose string, had never appeared to him to have the gravity now ascribed to it, 
and that Orfila knew perfectly well how to make allowance for the disturbance 
of functions peculiar to the operation. We may add that, after the vote on the 
conclusions of the report of the committee, which were considerably modified, on 
the motion of Dr. Devergie, Dr. Yelpeau expressed the regret that, before pro- 
ceeding to a somewhat precipitate vote, the Academy did not take into con- 
sideration a letter from Dr. Nonat, in which this gentleman declares that a series 
of twenty-two experiments made by him fifteen years since, with Messrs. San- 
dras, Deville, and Guibourt, will convince any one who will read the details, that 
the ligature of the oesophagus has never occasioned any accidents of a nature to 
cast doubts upon the results of toxicological researches. 

The upshot of these contradictory assertions is, in our estimation, a very posi- 



2t4 Progress or the Medical Sciences. [Jan. 

tive fact, viz, that the ligature of the CESophagus was performed by Messrs. 
Bouley and Keynal, if not with less care, at least otherwise than by Orfila. The 
whole question here lies in the difference of the manner of operating. It is for 
experimentalists to investigate that of the master ; but, in the mean time, we 
cannot see, in the conclusions of the report of the committee, matter important 
enough to assail the imperishable monument raised to the science of poisons by 
the great and noble mind of Orfila. — Dublin Hosp. Gaz., Oct. 1, 1858, from 
Journal of Pract. Med. and Surg. 



MISCELLANEOUS. 

46. Ozonometer. — Dr. Lankester exhibited to the Chemical Section of the 
British Association for the Advancement of Science, at its late meeting in Leeds, 
an instrument for measuring the constant intensity of ozone. This instrument 
consisted of two small rollers included in a box, which were moved by means of 
ordinary clockwork. Over the roller a strip of paper, prepared with iodide of 
potassium and starch is allowed to revolve, the paper becoming exposed to the 
air for an inch of its surface in the lid of the box. Twenty-four inches of paper 
pass over the rollers in the course of twenty-four hours, and thus registers, by its 
colour, the intensity of the action of ozone in the atmosphere. By this instru- 
ment, the intensity of the ozone for every hour in the twenty-four could be regis- 
tered, and minima and maxima, with an average, ascertained. The register 
of ozone could also be compared with those of the anemometer, and the relation 
of ozone to the direction and force of the wind ascertained. Dr. Lankaster 
pointed out the importance of ascertaining the presence of ozone, on account of 
its undoubted relation to health. He drew attention to a series of tables which 
had been drawn up from the registrations of the anemometer made at London, 
Blackheath, and Felixstow, on the coast of Suffolk. From these it was seen that 
the relation of these three places was 0, 22, and 55. The instrument acted also 
as a clock, and the time could be accurately marked upon the ozonized paper. 

Mr. Marshall made some remarks on his own observations during the last 
twelve months, and stated that he had not been able to discover, though assisted 
in the investigation by medical gentlemen, that there was any obvious connec- 
tion between ozone and the state of health. — British Med. Journ., Oct. 16, 1858. 



1859.] 



275 



AMERICAN INTELLIGENCE. 

ORIGINAL COMMUNICATIONS. 

A someivhat Remarkable Case of Strangulated Hernia. By Walter 
F. Atlee, M. D. 

The following case of strangulated hernia appears to be worthy of being 
recorded, from the long persistence of the symptoms after relief had been 
afforded to the obstruction, by an operation, and also from the nature of 
the matters vomited. 

Mrs. S , aged 60, residing in Logan Street, in this city, after suffer- 
ing from Saturday until the afternoon of the ensuing Wednesday from 
strangulation of a femoral hernia, of six years' standing, for which a band- 
age had never been worn, consented to undergo an operation for its relief. 
Stercoraceous vomiting had then existed for twenty-four hours, before her 
attending physician. Dr. Shapleigh, could obtain her consent to his calling 
in any further aid from a surgeon. 

The contents of the sac — which was about 7 inches in circumference — 
consisting of both intestine and omentum, were reduced after enlarging the 
opening in Poupart's ligament, and dividing freely the neck of the sac 

The stercoraceous vomiting, however, continued until the following Sun- 
day, when early in the morning an enormous discharge of feces occurred 
from the bowels, and all symptoms of strangulation ceased. The day after 
the operation enemata containing assafoetida were administered, and soon 
afterwards the matters that were thrown off from the mouth contained that 
substance, or, at least, were most strongly impregnated by its odour. 

The patient entirely recovered. 



DOMESTIC SUMMAEY. 

On the Action of Certain Vegetable Diuretics. By William A. Hammond, 
M. D., Assistant Surgeon XJ. S. Army. — The ensuing investigations consist mainly 
of repetitions of those performed some years since by Krahmer, and subsequently 
by Bird. They have reference to the appreciation of the influence of squill, juni- 
per, digitalis, and colchicum, over the quantity of the urine, its specific gravity 
and the amount of its solid organic and inorganic constituents. They were all 
performed upon healthy adult males. 

The quantity of urine was determined in cubic centimetres, and the weight of 
solids in grammes. 

The method employed for the determination of the whole amount of solid mat- 
ter was as follows : — 

Ten cubic centimetres of the urine were evaporated to as complete dryness as 
possible m vcccuo over sulphuric acid, and the residue accurately weighed. By 
simple proportion the amount of solids in the whole quantity of urine was easily 
ascertained. 

Although it is impossible to get rid of all the water by this process, the quan- 



276 



American Intelligence. 



[Jan. 



tity remaining is extremely small, and the results obtained are far more accurate 
than those yielded by evaporating to dryness in the water-bath as generally prac- 
tised. No matter how carefully this latter method is conducted, the loss of urea 
by decomposition is always an important item, and involves far more serious 
errors than the imperfect desiccation by the former process. 

For the determination of the amounts of organic and inorganic constituents 
separately, the solid residue obtained as above was mixed with ten or fifteen 
drops of moderately strong nitric acid, and gently heated till the mass was well 
dried. The heat was then gradually raised till all the carbon was consumed, and 
the mass in consequence became white. It was then cooled in vacuo over sul- 
phuric acid and weighed. The inorganic matter was thus determined and the loss 
showed the proportion of organic substance. 

Digitalis. — The subject of the experiments with this substance, was about 
twenty-five years of age and in good health. For the three days immediately 
preceding the commencement of the investigations the average quantity of urine 
daily excreted by him was 1474.5 cubic centimetres, the specific gravity was 
1024.30, and the average total amount of solid matter was 75.31 grammes, of 
which 30.17 grammes were inorganic, and 45.14 organic constituents. The digi- 
talis was given in the form of the officinal tincture in doses of 20 minims three 
times in 24 hours, and was continued for three consecutive days. During this 
period the manner of living (food, drink exercise, &c.,) was as nearly as possible 
the same as during the preliminary investigations. 

1st day. The urine passed on this day was of a pale straw colour and feeble 
acid reaction; quantity 1950 cubic centimetres; specific gravity 1013.25 ; total 
solids 69.98 grammes, of which amount 31.27 were inorganic and 38.71 organic 
matter. The action of the digitalis was not manifested otherwise than by its 
efifect upon the urine. 

2d day. The urine passed on this day was of similar physical character to that 
above mentioned. The quantity was 1873.6 centimetres, the specific gravity 
1014.32, and the total solids 63.74 grammes. The inorganic solids aMounted to 
30.15 grammes, and the organic to 33.49. 

The pulse on this day was somewhat slower and fuller than on the previous 
day. 

3d day. The quantity of urine evacuated on this day was 1624.9 cubic centi- 
metres, and of specific gravity 1020.04. The total amount of solid matter was 
67.29 grammes, of which 33.19 were inorganic and 34.10 organic. 

The colour, reaction, and odour of the urine were similar to those of the two 
previous days. 

The characteristic efi'ects of the digitalis upon the action of the heart were well 
marked during this day. 

The efi'ect of the digitalis in increasing the amount of urine is seen to have been 
greatest on the first day. On the second day it had fallen somewhat, and on the 
third was but 150 cubic centimetres greater than when no digitalis was taken. 
The solids, it is seen, were less than the normal standard from the commence- 
ment, were still further reduced on the second day, and on the third were slightly 
increased. This diminution is perceived to have been owing to the lessened 
amount of organic matter excreted. The inorganic substances were somewhat 
increased in amount over the ordinary proportion. 

Juniper. — The experiments with this substance were conducted on a healthy 
man thirty-five years of age. The average condition of his urine for the three days 
immediately preceding the investigations was as follows : quantity 1237.5 cubic 
centimetres, specific gravity 1022.50; total solids 61.23 grammes, of which 23.12 
were inorganic, and 38.11 organic matter. It was of ordinary colour and odour, 
and of strong acid reaction. 

Sixteen ounces of the officinal infusion of the berries of the Juniperus commu- 
nis were taken during the twenty-four hours, and the manner of living kept as 
nearly as possible to correspond with that of the preliminary experiments. 

1st day. For this day the quantity of urine amounted to 1732 cubic centime- 
tres, the specific gravity of which was 1016.38 ; the total solids were 62.75 
grammes; of this amount 25.43 grammes were inorganic, and 37.32 organic con- 
stituents. 



1859.] 



Domestic Summary. 



211 



The urine was of a pale straw colour and gave off the characteristic odour pro- 
duced by juniper. The reaction was feebly acid. 

2d day. The quantity of urine passed on this day was 1885,2 cubic centimetres. 
The specific gravity was 1014,15, and the total solids 58.49 grammes, 22,17 of 
which were inorganic, and 36.22 organic matter. The physical characteristics 
were similar to those of the day before. The reaction was barely acid. 

3d day. On this day the quantity of urine was 1672.5 cubic centimetres, with a 
specific gravity of 1018.41. The total solids amounted to 63.27 grammes, of which 
27.50 where inorganic, and 35.73 organic matter. The physical characteristics 
and reaction were the same as on the previous day. 

From these experiments it is seen that whilst the quantity of urine was materi- 
ally increased by the juniper, the amount of solid matter, as a whole, was but 
slightly affected, the loss in organic matter being about compensated for by the 
increase in the inorganic. 

Squill. — The experiments with this substance were instituted upon myself, and 
were conducted upon the same general principles as the foregoing series. The 
average daily quantity of urine, for the three days preceding the investigations, 
was 1358 cubic centimetres. The specific gravity was 1023.51, and the total 
solids 69.35 grammes; of this amount 27.22 were inorganic, and 42.13 organic 
matter. 

I took two grains of the dried bulb of the Scilla maritima, three times in the 
twenty-four hours. The other conditions remaining the same as in the prelimi- 
nary examination of the urine. 

1st day. The quantity of urine passed on this day was 1572 cubic centimetres 
of 1020.34 specific gravity. The total solid matter was 6067 grammes, 31.07 of 
this amount being inorganic, and 29.60 organic constituents. The urine was of 
feeble acid reaction. 

2d day. Quantity of urine 1493.5 cubic centimetres, specific gravity 1020.90, 
total solids 58.22 grammes, inorganic matter 30.15, organic 28.07 grammes. The 
reaction, &c., were the same as on the preceding day. 

3d day. On this day the quantity of urine amounted to 1535 cubic centimetres, 
and was of 1019.37 specific gravity. The total amount of solid matter was 61.58 
grammes, of which 30.58 were inorganic, and 31.00 organic constituents. The 
reaction, colour, &c., were unchanged. 

From the above experiments it is percieved that the action of the squill was 
similar to that of the digitalis and juniper, i. e., causing an increase in the water 
of the urine and inorganic solids, but a reduction of the amount of organic mat- 
ter. The loss of organic matter was considerably greater than with either of the 
other substances. 

Colchicum. — The investigations into the action of this substance were per- 
formed upon a healthy man 28 years of age. The urine for the three days imme- 
diately preceding the commencement of the experiments, was of the following 
daily average character; Quantity 1230 cubic centimetres, specific gravity 
1025.08 ; total solids 63.12 grammes, inorganic matter 29.83 and organic 33.29. 
The reaction was very strongly acid. 

One and a half drachms of the officinal tincture of the seeds of the Colchicum 
autumnale were given three times in twenty-four hours, and continued for three 
days. During this period the food, exercise, &c., were as nearly as possible the 
same as during the preliminary series. 

1st day. The quantity of urine passed on this day was 1595.7 cubic centime- 
tres, with a specific gravity of 1024.37. The total solids amounted to 77.29 
grammes, the inorganic matter of which was 36.50 grammes, and the organic 
20.79 grammes. The reaction was strongly acid. 

2d day. Quantity of urine 1484.1 cubic centimetres, specific gravity 1024.31 ; 
total solids 75.22 grammes. The amount of inorganic matter was 35.01 grammes, 
and of organic 40.21. The reaction was very strongly acid. 

3d day. On this day the quantity of urine amounted to 1620 cubic centimetres, 
and was of 1022.06 specific gravity. The total amount of solid matter was 79.33 
grammes, of which 34.20 were inorganic, and 45.13 organic constituents. Ee- 
action strongly acid. 

It is thus perceived that the action of the colchicum, as compared with that of 



2T8 



American Intelligence. 



[Jan. 



the other substances experimented with, was very remarkable, it being the only 
one with which there was an increase in the amount of solid matter eliminated, 
both organic and inorganic. 

From the foregoing experiments the following table embracing the averages 
of each series of investigations is constructed. 



■ 


Quantity 
of urine. 


Specific 
gravity. 


Total 
solids. 


Inorganic 
solids. 


Organic 
solids. 




1474.5 
1822.8 


1024.30 
1015.87 


75.31 
67.00 


30.17 
31.54 


45.14 
35.43 




1237.5 
1763.2 


1022.50 
1016.28 


61.23 
61.50 


23.12 
25.03 


38.11 
36.42 




1358.0 
1533.5 


1023.51 
1020.20 


69.35 
60.15 


27.22 
30.60 


42.13 
29.55 




1280.0 
1556.6 


1025.08 
1023.58 


63.12 
77.28 


29.83 
35.23 


33.29 
42.04 



From the foregoing investigations, I think it is deducible that neither digitalis, 
juniper, nor squill, increases the total amount of solid mater eliminated by the 
kidneys, and that the organic matter is considerably reduced through their in- 
fluence. Although they do increase the amount of inorganic matter removed 
through the urine, yet as it is the organic matter which is generally considered 
as contaminating the blood in disease, it is evident they exert no effect whatever 
in depurating this fluid, but on the contrary are positively injurious. 

The results obtained, in so far as the experiments with digitalis, squill, or juni- 
per, are concerned, are similar to those obtained by Krahmer, but are materially 
different as regards the colchicum. For, although Krahmer found that under the 
influence of this medicine there was an increase in the amount of organic matter 
excreted, this was so small as to lead to the supposition that it may have been 
accidental, and besides there was a reduction in the quantity of inorganic sub- 
stance removed. It is desirable, therefore, that we should have further observa- 
tions with this article. — Proc. Biol. Depart, Acad. Nat. Sciences of Philadelphia, 
Dec, 1858. 

Clinical Study of the Heart-sounds. — Prof. Austin Flint has published {New 
Orleans Med. News and Hospital Gazette, Se^t. and Oct., 1858) two very in- 
teresting letters on this subject. The following series of propositions are given 
by him as embodying the practical points pertaining to the diagnostic significa- 
tion of the abnormal modification of the heart-sounds : — 

1. Increased intensity of the first sound, the two elements composing this 
sound being affected equally, is a sign of excited, muscular action of the heart, 
and is observed in cases of functional disorder without organic disease. 

2. Increased intensity of the element of impulsion in the first sound, the in- 
tensity of the valvular element not being proportionately augmented, if at all, is 
a sign of hypertrophy affecting the left ventricle. 

3. Diminished intensity of the element of impulsion is a sign of weakened 
' muscular power of the left ventricle, either from organic affections, such as dila- 
tation, or fatty degeneration, or from functional debility of the organ. Cases 
are to be excluded in which, from the presence of liquid effusion in the pericar- 
dium or pleura, or from emphysema, the heart is prevented from coming into 
contact with the thoracic walls. 

4. Abnormal intensity of the mitral valvular element of the first sound, is a 
sign of excited muscular action of the heart, and is accompanied by a corre- 
sponding increase of the intensity of the element of impulsion, as stated in prop. 
1st. Abnormal weakness and suppression of this element, the element of impul- 
sion retaining or exceeding its normal intensity, are signs of more or less injury 
of the mitral valves. A murmur referable to the mitral orifice coexists in the 



1859.] 



Domestic Summary. 



279 



vast majority of cases. Notwithstanding the murmur, if the valvular element 
of the first sound referable to the mitral valves, retain nearly or quite its normal 
intensity, the valves are not seriously damaged. In judging of the normal inten- 
sity of the mitral valvular element, it may be compared with the sound emanating 
from the tricuspid valves. 

5. Abnormal intensity of the valvular element referable to the tricuspid valves, 
is a sign of hypertrophy of the right ventricle, and is generally associated with 
diminished intensity of the valvular element referable to the mitral valves. Ab- 
normal weakness of the tricuspid valvular element is not available as a physical 
sign of disease. 

6. A positive increase of the intensity of the pulmonic second sound of the 
heart, is a sign of hypertrophy of the right ventricle, in the majority of cases 
dependent on mitral contraction or insufficiency, or both. A relative increase of 
this sound, i. e., as compared with the aortic second sound, may result from 
abnormal feebleness of the aortic sound, due to mitral obstruction or regurgita- 
tion. 

7. Abnormal intensity of the aortic second sound, is not a sign of much im- 
portance. But non-diminution of its intensity, in cases in which a murmur 
referable to the aorta is present, is a sign of much value, indicating that, although 
aortic lesions exist, the integrity of the valves is not seriously compromised. 

8. Diminished intensity of the aortic second sound, in cases in which a murmur 
referable to the aorta is present, is a sign that the aortic valves are damaged, 
provided that neither mitral obstruction nor regurgitation exists, an effect of the 
latter being abnormal feebleness of this sound. If the diminished intensity of 
the aortic sound be due to injury of the valves of the aorta, there will be likely 
to be present an aortic regurgitant murmur, in other words, a diastolic murmur 
referable to the aorta. 

9. In cases in which a diastolic murmur is present, referable either to the direct 
current of blood through the mitral orifice, or to aortic regurgitation, a normal 
intensity of the aortic second sound is evidence that the lesions giving rise to the 
murmur are seated at the mitral orifice. 

Report of thirteen Gases of Ununited Fracture treated hy Suhcutaneous Per- 
foration of the Bone. — Prof. Brainard states [Chicago Medical Journ., Sept., 
1858), that since the publication of his essay on this mode of treating fractures 
( Trans. Am. Med. Assoc., vol. vii. 1854) , a more extended experience has enabled 
him to form a more just appreciation of the value of this treatment, to ascertain 
its advantages and defects, and to suggest some improvements in the manner of 
its performance ; and further, that the views formerly expressed concerning the 
efficacy and safety of the operation are in the main confirmed. 

Of the 13 cases of ununited fracture reported in the present paper, /o?tr were 
of the humerus; four of the femur ; three of the tibia, and two of the ulna. 

1. Of the humerus. — The first of these was of four months' standing, in a healthy 
man, 30 years of age. Two operations at an interval of ten days were performed, 
and a cure effected in one month. 

The second was of eight months' standing, in a healthy man, 29 years of age. 
Four operations by perforation were performed at intervals of ten days. Union 
was advancing, but the patient then put himself under the care of another sur- 
geon. 

The third case was one of six months' standing, in a healthy man 24 years of 
age. Five operations were performed at intervals of a week, and a cure was 
effected in six weeks. 

The fourth case was of five months' standing, in a man whose age and general 
condition are not stated. He was treated for five weeks by six perforations 
without benefit. The seton and then resection were tried without producing 
union. 

2. Of the femur. — The first of these was in a man 35 years of age, delicate 
health, of five months' standing. Treatment by eleven perforations during five 
months; cure. 

The second was of four months' standing, in a man 56 years of age, treated by 
four operations, and cured in six weeks. 



280 



American Intelligence. 



[Jan. 



The tliird was also of four montlis' standing, in a healthy young man ; cured 
by four perforations. 

fourth case was of five months' standing, in a healthy man aged 36 years. 
Cured in four weeks by one operation. 

3. Tibia. — The first of these was of four months' standing, in a man cured in two 
weeks by one perforation. 

The second was in a man 25 years of age, of good constitution ; cured in five 
weeks by four perforations. 

The third was of seven months' standing, in a man of good constitution, 21 
years of age ; cured in four weeks by four perforations. 

4. Ulna. — ThQ first of these was in a labourer, and was of three months' stand- 
ing. Cured in 22 days by two perforations. 

The second in a man 35 years of age, a drunkard, of 18 weeks' standing ; cured 
in four weeks by two perforations. 

In none of the above cases, Dr. B. states, did any serious accident occur. ''In 
one," he observes, "a small abscess, and in another, a subject of bad constitution, 
some swelling, resembling erysipelas, which, however, soon subsided. These were 
the most serious results of about sixty perforations. We may therefore assert, 
with great certainty, that this operation, unless performed upon patients in a 
condition unfit for any operation, is entirely safe. 

It will also be noticed, that, while in cases of fracture of the. tibia, where appo- 
sition is perfect and the movement slight, a single perforation speedily induced 
union in a few days ; on the other hand, fractures of the humerus and of the femur 
did not, in most cases, require less than four operations, nor unite in less than 
four weeks, while one required five months and eleven perforations to effect a 
cure, and another did not unite at all. 

My practice at present is to commence the treatment by two or three perfora- 
tions of the bone through a single opening of the skin, using an instrument of 
small size, repeating this every ten days or two weeks, gradually increasing the 
size of the instrument and the extent of the wound of the bone, until tenderness 
and some swelling are induced. I have very uniformly found that when pain and 
throbbing are felt in the seat of fracture, union has commenced. 

Direction of the Perforator. — That point and direction of puncture should be 
chosen which affords the easiest access to the bony surfaces with least exposure 
of vessels. In many cases of oblique fracture, traversing the bones answers well. 
In others, as of the tibia, I have found that following the direction of fracture 
is best. In others, still, when the ends are not perfectly in contact, I make a 
perforation between, and direct the instrument first in one direction, then in the 
osher; while in others, still, the instrument can be passed most readily between 
the bones and attack them at the side. 

''Size of the Instrument. — In cases of ununited fracture of the tibia, or radius 
and ulna, where the ends are in contact and the wounds slight, I use a perforator 
no more than two or three millimetres in breadth ; while, in old cases, situated in 
the femur and humerus, and when there is great mobility, it is as well to use an 
instrument one-eighth of an inch and over in breadth. In such cases, very exten- 
sive wounding and perfect denudation is required. It was not found that the 
bones had in any case lost their natural feeling of density. 

''Causes of Want of Union. — In all the above cases, the causes of non-union 
were imperfect apposition, or a dressing admitting of too great mobility, or acci- 
dents producing displacements, or indocility of the patient. In three of the cases, 
the fragments were separated from each other by a sensible space, as shown by 
the instrument in perforating them. It is especially to be noticed, that the most 
efficient means for securing immobility were in every case conjoined with the 
treatment by perforation. These means were such as are generally known and 
used." 

A case of ununited fracture of the forearm, treated unsuccessfully by this 
method, will be found in the original department of this number, (p. 136-141.) 

Dislocation of the Fourth and Fifth Cervical Vertebrce. — Dr. W. M. Eyer 
records {Pacific Med. 8f Surg. Journ., Sept. 1858) a case of this rare accident. 
The subject of it was a girl 7 years of age, of lymphatic constitution, the daugh- 



1859.] 



Domestic Summary. 



281 



ter of Dr. Hepburn, of Mokelumne Hill. When seen by Dr. R., the patient's 
head " was most singularly and immovably fixed, much bent to the side, the ear 
approximating- but little in advance of the right shoulder, and in a position no 
child in a normal condition could for a moment assume ; the slightest motion 
tending to change the relative position of the head and body producing intense 
pain. 

" The father, Dr. Hepburn, an aged and very intelligent practitioner of medi- 
cine, had watched the child with a parent's solicitude for the six previous days 
and nights, and neither during sleeping or waking did the child move its head 
from the position it had assumed from the instant of the accident. As the right 
clavicle was fractured at the time, the Doctor was inclined at first to believe the 
child was favouring the fracture and was unwilling to entertain the unpleasant 
thought of so serious a complication as luxation of the spine. 

" The child had fallen six days previous to my visit, from a high bed, and is 
supposed to have struck the back and left side of her head. The father saw her 
within a half minute after, and found her head and neck distorted precisely as at 
the time of my examination ; there had been no change for six days. Such dis- 
tortion, I believed, must have arisen from muscular contraction or bony displace- 
ment. We examined every muscle whose contraction would be likely to produce 
the deformity